Basic Information
| Provider Information | |||||||||
| NPI: | 1689718645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACCALLUM | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D. O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 ROANE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253022334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043440096 | ||||||||
| FaxNumber: | 3043424725 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 LAIDLEY ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043440096 | ||||||||
| FaxNumber: | 3043424725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 02/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 1940 | WV | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3003403000 | 05 | WV | MEDICAID | MA4091223 | 01 | WV | MEDICARE PTAN | OTHER | P00426369 | 01 | WV | RAILROAD MEDICARE | OTHER |