Provider Demographics
NPI:1134342256
Name:ANDREW L MCCALL DPM PA
Entity type:Organization
Organization Name:ANDREW L MCCALL DPM PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-529-0229
Mailing Address - Street 1:2920 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-529-0229
Mailing Address - Fax:888-688-3439
Practice Address - Street 1:2920 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7554
Practice Address - Country:US
Practice Address - Phone:208-529-0229
Practice Address - Fax:888-688-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807308400Medicaid
ID1351211OtherMEDICARE INDIVIDUAL PTAN
IDP9335OtherBLUE CROSS OF IDAHO
ID000010150955OtherREGENCE BLUE SHIELD OF ID
ID5582350001Medicare NSC