Provider Demographics
NPI:1073166542
Name:CALLAHAN, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 GIBBONS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2657
Mailing Address - Country:US
Mailing Address - Phone:828-506-0947
Mailing Address - Fax:
Practice Address - Street 1:7 W RIDGELY RD STE A
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-5135
Practice Address - Country:US
Practice Address - Phone:443-274-5368
Practice Address - Fax:410-252-4590
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00007762081S0010X
MDA00011102081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine