Healthcare Provider Details

I. General information

NPI: 1205892452
Provider Name (Legal Business Name): SCOTT B CALLAHAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DIVISION ST
DERBY CT
06418-1326
US

IV. Provider business mailing address

301 LEAVENWORTH RD
SHELTON CT
06484-1841
US

V. Phone/Fax

Practice location:
  • Phone: 203-735-7421
  • Fax:
Mailing address:
  • Phone: 203-513-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0522
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: