Healthcare Provider Details

I. General information

NPI: 1003817404
Provider Name (Legal Business Name): CLIFFORD M GALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 GLENN HENDREN DR STE 108
LIBERTY MO
64068-3388
US

IV. Provider business mailing address

2609 GLENN HENDREN DR
LIBERTY MO
64068-3313
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-3515
  • Fax: 816-781-3517
Mailing address:
  • Phone: 816-781-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number04 23541
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD R4P55
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: