Provider Demographics
NPI:1376576454
Name:ELIZABETH F. CALLAHAN, M.D., LLC
Entity Type:Organization
Organization Name:ELIZABETH F. CALLAHAN, M.D., LLC
Other - Org Name:SKIN SMART DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDGMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-308-7546
Mailing Address - Street 1:5911 N HONORE AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2606
Mailing Address - Country:US
Mailing Address - Phone:941-308-7546
Mailing Address - Fax:941-308-7550
Practice Address - Street 1:5911 N HONORE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2606
Practice Address - Country:US
Practice Address - Phone:941-308-7546
Practice Address - Fax:941-308-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D1031789OtherCLIA
FL145A6OtherBC ID JONELLE
FL48310OtherBCBS PROVIDER NUMBER
FLY00CFOtherBBR BCBS PROVIDER#
FL1003844937OtherJONELLE'S NPI
FL1861504045OtherBRR NPI
FLAK933YOtherPTAN JAMIE RAISOR
FLME104122OtherJONELLE MEDICAL LICENSE
FL1235392424OtherNPI JAMIE RAISOR
FL8188371OtherJONELLE CIGNA PROVIDER NUMBER
FL1285828053OtherCP NPI
FL1477548808OtherEFC NPI
FL00A58OtherGROUP BC PROVIDER NUMBER
FL1376576454OtherGROUP NPI
FL7543592OtherAETNA PROVIDER NUMBER
FLU2122XMedicare PIN
FL48310ZMedicare PIN
FLP78765Medicare UPIN
FLH35265Medicare UPIN
FLME104122OtherJONELLE MEDICAL LICENSE
FL1235392424OtherNPI JAMIE RAISOR
FL00A58OtherGROUP BC PROVIDER NUMBER
FL10D1031789OtherCLIA
FLDD0030Medicare PIN
FLBZ846ZMedicare PIN