Basic Information
Provider Information | |||||||||
NPI: | 1205880507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALLAGHAN | ||||||||
FirstName: | MAUREEN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2901 BRIDGEPORT WAY W | ||||||||
Address2: |   | ||||||||
City: | UNIVERSITY PLACE | ||||||||
State: | WA | ||||||||
PostalCode: | 984664614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535347000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2901 BRIDGEPORT WAY W | ||||||||
Address2: |   | ||||||||
City: | UNIVERSITY PLACE | ||||||||
State: | WA | ||||||||
PostalCode: | 984664614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535347000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 12/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084H0002X | MD00020274 | WA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Hospice and Palliative Medicine | 2084N0400X | MD00020274 | WA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207RH0002X | MD00020274 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 2029355 | 05 | WA |   | MEDICAID |