Basic Information
| Provider Information | |||||||||
| NPI: | 1710920830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCALLY | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 W MERRICK RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115203743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168670102 | ||||||||
| FaxNumber: | 5168671857 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 W MERRICK RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115203743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168670102 | ||||||||
| FaxNumber: | 5168671857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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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 | 208800000X | 115718 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00425750 | 05 | NY | MEDICAID | 340002520 | 01 | PALMETTO GBA/RAILROAD MED | OTHER |