Basic Information
| Provider Information | |||||||||
| NPI: | 1063564243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2406 LIGHTHOUSE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305017401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705364352 | ||||||||
| FaxNumber: | 7705328165 | ||||||||
| Practice Location | |||||||||
| Address1: | 584 LANIER PARK DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305012000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705345208 | ||||||||
| FaxNumber: | 7705348512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0602X | 045050 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy |
ID Information
| ID | Type | State | Issuer | Description | 00906386A | 05 | GA | MEDICAID |