Provider Demographics
NPI:1487603379
Name:GALVIN, GARY J (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:GALVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1618
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1618
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46231-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34447600Medicaid
WI1043809OtherPHYSICIANS PLUS
WI60222OtherDEAN HEALTH INSURANCE
WI006813215Medicare PIN
WI1043809OtherPHYSICIANS PLUS
WI34447600Medicaid
WI112554375Medicare PIN
E93011Medicare UPIN
WIK400131896Medicare PIN