Provider Demographics
NPI:1861480931
Name:CALLAHAN, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2253
Mailing Address - Country:US
Mailing Address - Phone:978-514-6300
Mailing Address - Fax:978-514-6324
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 4
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2253
Practice Address - Country:US
Practice Address - Phone:978-514-6300
Practice Address - Fax:978-514-6324
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3141454Medicaid
MAA2028201Medicare PIN
MAG07307Medicare UPIN