Basic Information
| Provider Information | |||||||||
| NPI: | 1356443477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN KILGALLIN M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 DOWELL RD | ||||||||
| Address2: | |||||||||
| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426424278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708663161 | ||||||||
| FaxNumber: | 2708663163 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 DOWELL RD | ||||||||
| Address2: | |||||||||
| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426424278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708663161 | ||||||||
| FaxNumber: | 2708663163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KILGALLIN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2708663161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25723 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000202451 | 01 | KY | ANTHEM BC/BS | OTHER | 000000049266 | 01 | KY | ANTHEM BC/BS | OTHER | 65935983 | 05 | KY | MEDICAID | 78902103 | 05 | KY | MEDICAID |