Healthcare Provider Details

I. General information

NPI: 1720548050
Provider Name (Legal Business Name): MICHELLE T GAGLIA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF PEDIATRIC ANESTHESIOLOGY
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

1221 83RD ST
BROOKLYN NY
11228-3021
US

V. Phone/Fax

Practice location:
  • Phone: 800-879-2467
  • Fax:
Mailing address:
  • Phone: 917-848-6771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberOT024912
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: