Provider Demographics
NPI:1205065034
Name:MCCALLISTER, MARYJEAN (RD)
Entity type:Individual
Prefix:
First Name:MARYJEAN
Middle Name:
Last Name:MCCALLISTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1813 W KIRBY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5410
Practice Address - Country:US
Practice Address - Phone:217-383-3490
Practice Address - Fax:217-383-3439
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001Medicare NSC
IL6447860018Medicare NSC
ILIL3270257Medicare PIN