1700872116 NPI number — JEFFREY I KALISH CRNA

Table of content: JEFFREY I KALISH CRNA (NPI 1700872116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700872116 NPI number — JEFFREY I KALISH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALISH
Provider First Name:
JEFFREY
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700872116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 NOAH DR
Provider Second Line Business Mailing Address:
SUITE 113-315
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30143-8705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-301-1098
Provider Business Mailing Address Fax Number:
706-301-9151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
744 NOAH DRIVE
Provider Second Line Business Practice Location Address:
SUITE 113-315
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-301-1098
Provider Business Practice Location Address Fax Number:
706-301-9151
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  101-0031149 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 1724492 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 147022 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 3099A , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 048622-23-11 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1011062 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 995335579K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30342515 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3050611 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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