Provider Demographics
NPI:1467650614
Name:MARY K O'CALLAGHAN DO PC
Entity Type:Organization
Organization Name:MARY K O'CALLAGHAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KEATING
Authorized Official - Last Name:O'CALLAGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-845-7380
Mailing Address - Street 1:922 LAWNDALE ST
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1928
Mailing Address - Country:US
Mailing Address - Phone:231-845-7380
Mailing Address - Fax:
Practice Address - Street 1:922 LAWNDALE ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1928
Practice Address - Country:US
Practice Address - Phone:231-845-7380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI009391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5530004OtherBCBS #
MIDG2738OtherMEDICARE RR GROUP
MI2736118Medicaid
MI1155300045OtherBC GROUP
MI1155300045OtherBC GROUP
MI=========OtherPRIORITY HEALTH
MI=========OtherPPOM
MIBO0518834OtherDEA