Provider Demographics
NPI:1689881625
Name:MCCALLA, CHAD DAVID (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:DAVID
Last Name:MCCALLA
Suffix:
Gender:M
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-4195
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-4195
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.091483207PP0204X
NC2011-00079207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917702Medicaid
NCNC0072AMedicare PIN