1881661668 NPI number — KERRY M KALLAS M.D.

Table of content: KERRY M KALLAS M.D. (NPI 1881661668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881661668 NPI number — KERRY M KALLAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALLAS
Provider First Name:
KERRY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1881661668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1450 NW 6035
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485-6035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-542-8553
Provider Business Mailing Address Fax Number:
952-513-6857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 19TH STREET SOUTH
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-0609
Provider Business Practice Location Address Fax Number:
320-251-3806
Provider Enumeration Date:
03/01/2006

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: 2085R0202X , with the licence number:  40558 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 979669000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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