=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467784629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALLUP FAMILY PRACTICE,LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2010
-----------------------------------------------------
Last Update Date | 02/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W KENSINGTON RD SUITE 1 A
-----------------------------------------------------
City | MT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-483-0200
-----------------------------------------------------
Fax | 847-483-0201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 W KENSINGTON RD SUITE 1 A
-----------------------------------------------------
City | MT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-483-0200
-----------------------------------------------------
Fax | 847-483-0201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD E. GALLUP
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-483-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036090453
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------