Basic Information
| Provider Information | |||||||||
| NPI: | 1104886720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLEGARI | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | DEPT OF PEDIATRICS | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | DEPT OF PEDIATRICS | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301046303 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1929 849 | 05 | MI | MEDICAID | OH 16115045 | 05 | MI | MEDICAID | 700H161150 | 01 | MI | BS | OTHER |