Healthcare Provider Details

I. General information

NPI: 1205910874
Provider Name (Legal Business Name): CALLAWAY INTERNAL MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 FAIRWAY DR SUITE D
FULTON MO
65251-3936
US

IV. Provider business mailing address

2613 FAIRWAY DR SUITE D
FULTON MO
65251-3936
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-4242
  • Fax:
Mailing address:
  • Phone: 573-642-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number113229
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number112907
License Number StateMO

VIII. Authorized Official

Name: DR. FREDERICK M WILSON
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 573-642-4242