Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207T00000X | Neurosurgeon | 04 23541 | KS |
Y | 207T00000X | Neurosurgeon | MD R4P55 | MO |
NPI | 1003817404 |
---|---|
Provider Name | Clifford M Gall |
First Address | Liberty, MO 64068-3313 |
Second Address | Liberty, MO 64068-3388 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
17554034 | BCBS (01) | MO |
E87101 | (02) |