MEDICARE: GALLUP FAMILY PRACTICE,LTD.

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	207Q00000X	Family Medicine Physician	036090453	IL

General Provider Information

NPI Number	:	1467784629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALLUP FAMILY PRACTICE,LTD.

Provider Business Mailing Address
First Line	:	250 W KENSINGTON RD
Second Line	:	SUITE 1 A
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1293
Country	:	US
Telephone Number	:	847-483-0200
Fax Number	:	847-483-0201

Provider Business Practice Location Address
First Line	:	250 W KENSINGTON RD
Second Line	:	SUITE 1 A
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1293
Country	:	US
Telephone Number	:	847-483-0200
Fax Number	:	847-483-0201

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD E. GALLUP
Credential	:	M.D.
Telephone Number	:	847-483-0200

Provider Enumeration Date	:	02/12/2010
Last Update Date	:	02/12/2010

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