Healthcare Provider Details

I. General information

NPI: 1841475803
Provider Name (Legal Business Name): NORTHWEST COSMETIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SW MILL VIEW WAY SUITE 100
BEND OR
97702-1140
US

IV. Provider business mailing address

777 SW MILL VIEW WAY STE 250
BEND OR
97702-1140
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-1022
  • Fax: 541-322-7002
Mailing address:
  • Phone: 541-728-3184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD21961
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. GARY LYLE GALLAGHER
Title or Position: MANAGER/MEMBER
Credential: M.D.
Phone: 417-283-1845