Provider Demographics
NPI:1558369884
Name:OCALLAGHAN, MARY KEATING (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KEATING
Last Name:OCALLAGHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 N JEBAVY DR
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1208
Mailing Address - Country:US
Mailing Address - Phone:231-510-6877
Mailing Address - Fax:
Practice Address - Street 1:889 N JEBAVY DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1208
Practice Address - Country:US
Practice Address - Phone:231-510-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110088230OtherMEDICARE RAILROAD
MI1155300045OtherBCBS #
MI382911834OtherPRIORITY HEALTH
MI382911834OtherPPOM
MI2736118Medicaid
MIBO0518834OtherDEA
MI5530004OtherOLD MEDICARE
MI0P47070001Medicare PIN