=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215055611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN CALLAHAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 MARPLE RD
-----------------------------------------------------
City | BROOMALL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19008-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-356-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 79 WORRELL DR
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-541-0694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OP001927L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------