Provider Demographics
NPI:1679615900
Name:MCCALLUM, TIMOTHY DALE (MA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DALE
Last Name:MCCALLUM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 FRANKLIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-1044
Mailing Address - Country:US
Mailing Address - Phone:585-335-3640
Mailing Address - Fax:585-335-3667
Practice Address - Street 1:117 FRANKLIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-1044
Practice Address - Country:US
Practice Address - Phone:585-335-3640
Practice Address - Fax:585-335-3667
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000244-1231H00000X
NY14000010454237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01304503Medicaid
NY11804CMedicare ID - Type Unspecified