1568671964 NPI number — DR. MICHAEL DOUGLAS CALLAN D.O.

Table of content: DR. MICHAEL DOUGLAS CALLAN D.O. (NPI 1568671964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568671964 NPI number — DR. MICHAEL DOUGLAS CALLAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAN
Provider First Name:
MICHAEL
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1568671964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 FORT STREET
Provider Second Line Business Mailing Address:
SUITE D ATTN DENISE
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-391-3057
Provider Business Mailing Address Fax Number:
734-391-3052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2070 BIDDLE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WYANDOTTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48192-4080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-225-9100
Provider Business Practice Location Address Fax Number:
734-225-9176
Provider Enumeration Date:
05/22/2007

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: 207XP3100X , with the licence number:  5101016780 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0114X , with the licence number: 5101016780 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0H28427 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1699102244 . This is a "GROUP NPI HENRY FORD WYANDOTTE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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