Provider Demographics
NPI:1659577690
Name:CALLAWAY CLINIC L L C
Entity Type:Organization
Organization Name:CALLAWAY CLINIC L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-769-2803
Mailing Address - Street 1:489 N TYNDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6126
Mailing Address - Country:US
Mailing Address - Phone:850-769-2803
Mailing Address - Fax:850-913-8046
Practice Address - Street 1:489 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6126
Practice Address - Country:US
Practice Address - Phone:850-769-2803
Practice Address - Fax:850-913-8046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3368Medicare PIN
FLK3428Medicare PIN