Provider Demographics
NPI:1588727259
Name:MARK T CALLESEN MD PC
Entity type:Organization
Organization Name:MARK T CALLESEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:CALLESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-464-4606
Mailing Address - Street 1:1201 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 11750
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2008
Mailing Address - Country:US
Mailing Address - Phone:480-464-4606
Mailing Address - Fax:480-464-0613
Practice Address - Street 1:1201 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 11750
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-2008
Practice Address - Country:US
Practice Address - Phone:480-464-4606
Practice Address - Fax:480-464-0613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23058323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility