MEDICARE: DR. RENEE GALLO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	ME119631	FL
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	ME119631	FL
3	208VP0000X	Pain Medicine Physician	ME119631	FL

General Provider Information

NPI Number	:	1043524119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENEE GALLO M.D.

Provider Business Mailing Address
First Line	:	2023 MYRA ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-3714
Country	:	US
Telephone Number	:	904-503-5464
Fax Number	:	904-575-4399

Provider Business Practice Location Address
First Line	:	2023 MYRA ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-3714
Country	:	US
Telephone Number	:	904-503-5464
Fax Number	:	904-575-4399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2010
Last Update Date	:	09/11/2023

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