Healthcare Provider Details

I. General information

NPI: 1518965375
Provider Name (Legal Business Name): MARK JOSEPH GALLOWAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 N FRASER ST
GEORGETOWN SC
29440-6418
US

IV. Provider business mailing address

2185 N FRASER ST
GEORGETOWN SC
29440-6418
US

V. Phone/Fax

Practice location:
  • Phone: 843-527-1800
  • Fax: 843-527-6528
Mailing address:
  • Phone: 843-527-1800
  • Fax: 843-527-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA100036000
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: