Healthcare Provider Details

I. General information

NPI: 1871790733
Provider Name (Legal Business Name): MICHELLE L. GALLAGHER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE L. RANDALL D.O.

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E MOUNT HOPE AVE
LANSING MI
48910-3207
US

IV. Provider business mailing address

601 ANHINGA DR
EAST LANSING MI
48823-8364
US

V. Phone/Fax

Practice location:
  • Phone: 517-485-1153
  • Fax:
Mailing address:
  • Phone: 517-331-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5315025963
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: