Provider Demographics
NPI:1205910874
Name:CALLAWAY INTERNAL MEDICINE GROUP
Entity type:Organization
Organization Name:CALLAWAY INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-642-4242
Mailing Address - Street 1:2613 FAIRWAY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-3936
Mailing Address - Country:US
Mailing Address - Phone:573-642-4242
Mailing Address - Fax:
Practice Address - Street 1:2613 FAIRWAY DR
Practice Address - Street 2:SUITE D
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-3936
Practice Address - Country:US
Practice Address - Phone:573-642-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113229174400000X
MO112907174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty