Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 36001023A | IN |
N | 213ES0000X | Sports Medicine | 36001023A | IN |
NPI | 1063409332 |
---|---|
Provider Name | Mr. Jeremy R. Gall |
First Address | Fort Wayne, IN 46845-2110 |
Second Address | Fort Wayne, IN 46804-4133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2005 |
Last Update Date | 16/06/2018 |