Provider Demographics
NPI:1518906254
Name:O'CALLAGHAN, ROBERT MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:O'CALLAGHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:R
Other - Middle Name:MICHAEL
Other - Last Name:O'CALLAGHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:55 ELVA CT
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1875
Mailing Address - Country:US
Mailing Address - Phone:937-208-7525
Mailing Address - Fax:937-208-7515
Practice Address - Street 1:55 ELVA CT
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1875
Practice Address - Country:US
Practice Address - Phone:937-208-7525
Practice Address - Fax:937-208-7515
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0106363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067901Medicaid
OHPA23952Medicare PIN
OHPA23951Medicare PIN
OH0067901Medicaid