1891965505 NPI number — KEVIN J KALLAL MD PA

Table of content: (NPI 1891965505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891965505 NPI number — KEVIN J KALLAL MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN J KALLAL MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KALLAL MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1891965505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5015 FORT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76710-5828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-431-0606
Provider Business Mailing Address Fax Number:
817-379-0155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 N RUFE SNOW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76248-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-431-0606
Provider Business Practice Location Address Fax Number:
817-379-0155
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KALLAL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
817-431-0606

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  H7766 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861408205 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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