Provider Demographics
NPI:1053454793
Name:CHARLES M. CALLAHAN, M.D. P.A.
Entity Type:Organization
Organization Name:CHARLES M. CALLAHAN, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-569-8094
Mailing Address - Street 1:3730 7TH TER
Mailing Address - Street 2:SUITE 302A
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7324
Mailing Address - Country:US
Mailing Address - Phone:772-569-8094
Mailing Address - Fax:772-299-5875
Practice Address - Street 1:3730 7TH TER
Practice Address - Street 2:SUITE 302A
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7324
Practice Address - Country:US
Practice Address - Phone:772-569-8094
Practice Address - Fax:772-299-5875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68793174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32776AMedicare ID - Type UnspecifiedMEDICARE PROVIDER
FLG46486Medicare UPIN