Provider Demographics
NPI:1104886720
Name:CALLEGARI, MARY JANE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:CALLEGARI
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 1:5301 E HURON RIVER DR
Mailing Address - Street 2:DEPT OF PEDIATRICS
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1051
Mailing Address - Country:US
Mailing Address - Phone:734-712-3325
Mailing Address - Fax:
Practice Address - Street 1:5301 E HURON RIVER DR
Practice Address - Street 2:DEPT OF PEDIATRICS
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1929 849Medicaid
MIOH 16115045Medicaid
MI700H161150OtherBS
MI1929 849Medicaid