Basic Information
| Provider Information | |||||||||
| NPI: | 1114951852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACCALLUM | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | MARIBEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005047 | ||||||||
| FaxNumber: | 4342006490 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 THOMSON DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005925 | ||||||||
| FaxNumber: | 4342005929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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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 | 174400000X | 0101239992 | VA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0101239992 | 01 | VA | MEDICAL LICENSE NUMBER | OTHER | 010294941 | 05 | VA | MEDICAID |