Provider Demographics
NPI:1528016094
Name:MCCALLA, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCALLA
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 1:1719 KIRBY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4367
Mailing Address - Country:US
Mailing Address - Phone:901-274-5786
Mailing Address - Fax:901-726-6120
Practice Address - Street 1:1719 KIRBY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4367
Practice Address - Country:US
Practice Address - Phone:901-274-5786
Practice Address - Fax:901-726-6120
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA99222Medicare UPIN
TN3028300Medicare ID - Type UnspecifiedMEDICARE