Provider Demographics
NPI:1497762793
Name:CALLEN, MATTHEW BRENT (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BRENT
Last Name:CALLEN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:7425 FORSYTH
Mailing Address - Street 2:C B 8221
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2161
Mailing Address - Country:US
Mailing Address - Phone:314-454-2810
Mailing Address - Fax:314-454-2818
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:SUITE 4E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-2810
Practice Address - Fax:314-454-2818
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2004002147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097090Medicare PIN