Healthcare Provider Details

I. General information

NPI: 1720058084
Provider Name (Legal Business Name): EDWARD RAYMOND GALLAGHER II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SEABEE DR PHIBCB TWO
VIRGINIA BEACH VA
23459-8917
US

IV. Provider business mailing address

1815 SEABEE DR PHIBCB TWO
VIRGINIA BEACH VA
23459-8917
US

V. Phone/Fax

Practice location:
  • Phone: 757-462-8710
  • Fax:
Mailing address:
  • Phone: 757-462-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: