1891785671 NPI number — RICHARD Q CALLAHAN MSPA, PA-C

Table of content: RICHARD Q CALLAHAN MSPA, PA-C (NPI 1891785671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891785671 NPI number — RICHARD Q CALLAHAN MSPA, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAHAN
Provider First Name:
RICHARD
Provider Middle Name:
Q
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPA, PA-C
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:
1891785671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 COLCHESTER AVE
Provider Second Line Business Mailing Address:
DERMATOLOGY - ACC/WP-5
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-1473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-847-4570
Provider Business Mailing Address Fax Number:
802-847-3364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
DERMATOLOGY - ACC/WP-5
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-1473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-4570
Provider Business Practice Location Address Fax Number:
802-847-3364
Provider Enumeration Date:
10/24/2005

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: 363AS0400X , with the licence number:  055-0030786 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 055-0030786 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 055-0030786 . This is a "LICENSE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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