Provider Demographics
NPI:1902902380
Name:CALLANAN, KEITH E (MPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:CALLANAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-4415
Mailing Address - Country:US
Mailing Address - Phone:781-297-0979
Mailing Address - Fax:781-297-3703
Practice Address - Street 1:1519 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4415
Practice Address - Country:US
Practice Address - Phone:781-297-0979
Practice Address - Fax:781-297-3703
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67872OtherBCBS
MAY68748Medicare ID - Type Unspecified