MEDICARE: MS. FAWN SERENE CALLIE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	101963	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00238952	OTHER	NC	RETIRED RAILROAD MEDICARE

General Provider Information

NPI Number	:	1932184611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. FAWN SERENE CALLIE PA-C

Provider Business Mailing Address
First Line	:	103 DOE COURT
Second Line	:
City	:	HAMPSTEAD
State	:	NC
Zip	:	28443
Country	:	US
Telephone Number	:	910-214-0475
Fax Number	:	919-735-0582

Provider Business Practice Location Address
First Line	:	2707 MEDICAL OFFICE PL
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-9458
Country	:	US
Telephone Number	:	919-735-9146
Fax Number	:	919-735-0582

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	02/27/2023

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