Healthcare Provider Details

I. General information

NPI: 1114487758
Provider Name (Legal Business Name): JARED GALLOWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6045 BRIDGETOWN RD
CINCINNATI OH
45248-3049
US

IV. Provider business mailing address

234 GOODMAN ST, ML0781 INTERNAL MEDICINE
CINCINNATI OH
45219-2364
US

V. Phone/Fax

Practice location:
  • Phone: 513-981-4105
  • Fax: 513-347-4620
Mailing address:
  • Phone: 513-584-4505
  • Fax: 513-584-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35145395
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: