Healthcare Provider Details

I. General information

NPI: 1538122726
Provider Name (Legal Business Name): SCOTT DANIEL CALLAHAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2006
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

PO BOX 701938
PLYMOUTH MI
48170-0973
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3456
  • Fax:
Mailing address:
  • Phone: 734-678-8992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704196379
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: