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General NPI Number Information
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NPI Number | 1497762793
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Entity Type | Individual
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Provider Name | MATTHEW BRENT CALLEN PA
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 07/15/2008
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Provider Practice Location Address
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Address Line | 1 CHILDRENS PL SUITE 4E
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City | SAINT LOUIS
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State | MO
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Zip | 63110-1002
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Country | US
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Telephone | 314-454-2810
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Fax | 314-454-2818
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Provider Business Mailing Address
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Address Line | 7425 FORSYTH C B 8221
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City | SAINT LOUIS
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State | MO
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Zip | 63105-2161
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Country | US
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Telephone | 314-454-2810
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Fax | 314-454-2818
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2004002147
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License Number State | MO
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