MEDICARE: RUSSELLVILLE DERMATOLOGY CLINIC PA

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	207NS0135X	Procedural Dermatology Physician	MC0841	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477529436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE DERMATOLOGY CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 843
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72811-0843
Country	:	US
Telephone Number	:	479-968-6969
Fax Number	:	479-968-4290

Provider Business Practice Location Address
First Line	:	1602 W MAIN ST
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-2720
Country	:	US
Telephone Number	:	479-968-6969
Fax Number	:	479-968-4290

Authorized Official
Title or Position	:	PRESIDENT / OWNER
Name	:	DR. WILLIAM W GALLOWAY
Credential	:	M.D.
Telephone Number	:	479-968-6969

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	03/07/2023

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Directions to “RUSSELLVILLE DERMATOLOGY CLINIC PA ” Practice Location

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