1295772671 NPI number — BRAD CALLAN MSPT

Table of content: BRAD CALLAN MSPT (NPI 1295772671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295772671 NPI number — BRAD CALLAN MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAN
Provider First Name:
BRAD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295772671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1188 106TH AVE NE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-8614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-454-4864
Provider Business Mailing Address Fax Number:
425-646-3901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 NW GILMAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-392-6804
Provider Business Practice Location Address Fax Number:
425-392-6805
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00008322 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7131931 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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