1821105982 NPI number — LISA J KINSEY CALLAWAY M.D.

Table of content: LISA J KINSEY CALLAWAY M.D. (NPI 1821105982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821105982 NPI number — LISA J KINSEY CALLAWAY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINSEY CALLAWAY
Provider First Name:
LISA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1821105982
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 STATE ST SE
Provider Second Line Business Mailing Address:
STE 228
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-4328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-685-1808
Provider Business Mailing Address Fax Number:
616-685-1850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 JEFFERSON AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-5039
Provider Business Practice Location Address Fax Number:
616-685-3093
Provider Enumeration Date:
08/24/2006

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: 207R00000X , with the licence number:  4301070858 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 4301070858 , 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: 4196570 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104109912 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 38-2145264 . This is a "IRS" identifier . This identifiers is of the category "OTHER".