Basic Information
| Provider Information | |||||||||
| NPI: | 1346648862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | MED | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 568 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407020568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065287010 | ||||||||
| FaxNumber: | 6065285401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 AMERICAN GREETING CARD RD | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407014811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065287010 | ||||||||
| FaxNumber: | 6065285401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2014 | ||||||||
| LastUpdateDate: | 12/16/2014 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.