Healthcare Provider Details

I. General information

NPI: 1689718645
Provider Name (Legal Business Name): MATTHEW J MACCALLUM D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAIDLEY ST
CHARLESTON WV
25301-1614
US

IV. Provider business mailing address

110 ROANE ST
CHARLESTON WV
25302-2334
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-0096
  • Fax: 304-342-4725
Mailing address:
  • Phone: 304-344-0096
  • Fax: 304-342-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1940
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: