Provider Demographics
NPI:1205236973
Name:MCCALLUM, DAVID HARLEY (NP)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:HARLEY
Last Name:MCCALLUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 KING RD STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7909
Mailing Address - Country:US
Mailing Address - Phone:734-479-1944
Mailing Address - Fax:
Practice Address - Street 1:14700 KING RD STE A
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7909
Practice Address - Country:US
Practice Address - Phone:734-479-1944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704236050275N00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704236050OtherMI LICENSE