Provider Demographics
NPI:1386858447
Name:MCCALLISTER, JULIE N (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:N
Last Name:MCCALLISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 MACCORKLE AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309
Mailing Address - Country:US
Mailing Address - Phone:304-766-4400
Mailing Address - Fax:304-766-4417
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:STE 400
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-4400
Practice Address - Fax:304-766-4417
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV23689208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015753Medicaid