Provider Demographics
NPI:1033109863
Name:HAVASU MEDICAL CARE
Entity Type:Organization
Organization Name:HAVASU MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:CALLERAME
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-3007
Mailing Address - Street 1:1955 MCCULLOCH BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5748
Mailing Address - Country:US
Mailing Address - Phone:928-453-3007
Mailing Address - Fax:928-680-9663
Practice Address - Street 1:1955 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5748
Practice Address - Country:US
Practice Address - Phone:928-453-3007
Practice Address - Fax:928-680-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty