1376576454 NPI number — ELIZABETH F. CALLAHAN, M.D., LLC

Table of content: (NPI 1376576454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376576454 NPI number — ELIZABETH F. CALLAHAN, M.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH F. CALLAHAN, M.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SKIN SMART DERMATOLOGY
Provider Other Organization Name Type Code:
3
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:
1376576454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5911 N HONORE AVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34243-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-308-7546
Provider Business Mailing Address Fax Number:
941-308-7550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5911 N HONORE AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34243-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-308-7546
Provider Business Practice Location Address Fax Number:
941-308-7550
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIDGMORE
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
941-308-7546

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME89181 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10D1031789 . This is a "CLIA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 145A6 . This is a "BC ID JONELLE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 48310 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y00CF . This is a "BBR BCBS PROVIDER#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1003844937 . This is a "JONELLE'S NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1861504045 . This is a "BRR NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: AK933Y . This is a "PTAN JAMIE RAISOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME104122 . This is a "JONELLE MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1235392424 . This is a "NPI JAMIE RAISOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8188371 . This is a "JONELLE CIGNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1285828053 . This is a "CP NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1477548808 . This is a "EFC NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00A58 . This is a "GROUP BC PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1376576454 . This is a "GROUP NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7543592 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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