Provider Demographics
NPI:1295728475
Name:MACCALLUM, CHARLES L (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:MACCALLUM
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 1:5778 DARROW RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-3808
Mailing Address - Country:US
Mailing Address - Phone:330-655-2161
Mailing Address - Fax:330-650-2116
Practice Address - Street 1:5778 DARROW RD
Practice Address - Street 2:SUITE D
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-3808
Practice Address - Country:US
Practice Address - Phone:330-655-2161
Practice Address - Fax:330-650-2116
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040856M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMA0442995Medicare ID - Type Unspecified
OHA77411Medicare UPIN