MEDICARE: GARY M DALLEY 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	207R00000X	Internal Medicine Physician	045760	GA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629071873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY M DALLEY M.D.

Provider Business Mailing Address
First Line	:	2130 IMPERIAL DR
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-1315
Country	:	US
Telephone Number	:	770-287-1144
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 RIVER PL
Second Line	:	SUITE 200
City	:	BRASELTON
State	:	GA
Zip	:	30517-5602
Country	:	US
Telephone Number	:	770-848-6140
Fax Number	:	770-848-6141

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	01/29/2021

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