1528020559 NPI number — KEYSTONE ORTHOPEDIC SPECIALISTS S C

Table of content: DR. SCOTT D. CALLAGHAN D.O. (NPI 1497747018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528020559 NPI number — KEYSTONE ORTHOPEDIC SPECIALISTS S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE ORTHOPEDIC SPECIALISTS S C
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:
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:
1528020559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 WEST 177TH ST
Provider Second Line Business Mailing Address:
SUITE 2C
Provider Business Mailing Address City Name:
HAZEL CREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-799-1144
Provider Business Mailing Address Fax Number:
708-799-4899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 WEST 177TH ST
Provider Second Line Business Practice Location Address:
SUITE 2C
Provider Business Practice Location Address City Name:
HAZEL CREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-799-1144
Provider Business Practice Location Address Fax Number:
708-799-4899
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-799-1144

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 036074003 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CE8619 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8620 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000095658 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01620925 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 367659000 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".




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