Provider Demographics
NPI:1871606251
Name:CHRISTIAN GALLERY MD
Entity type:Organization
Organization Name:CHRISTIAN GALLERY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:GALLERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-385-3280
Mailing Address - Street 1:2644 M ST STE H
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-2826
Mailing Address - Country:US
Mailing Address - Phone:209-385-3280
Mailing Address - Fax:209-385-3286
Practice Address - Street 1:2644 M ST
Practice Address - Street 2:STE. H
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-2826
Practice Address - Country:US
Practice Address - Phone:209-385-3280
Practice Address - Fax:209-385-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66256208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099810Medicaid
CAZZZ65531ZOtherBLUE SHIELD GRP NUMBER
CAGR0099810Medicaid