1225015191 NPI number — DR. JEFFREY C KALT MD

Table of content: DR. JEFFREY C KALT MD (NPI 1225015191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225015191 NPI number — DR. JEFFREY C KALT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALT
Provider First Name:
JEFFREY
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1225015191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30301 WOODWARD AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48073-0981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-398-2525
Provider Business Mailing Address Fax Number:
248-398-9286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30301 WOODWARD AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-0981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-398-2525
Provider Business Practice Location Address Fax Number:
248-398-9286
Provider Enumeration Date:
12/30/2005

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: 207W00000X , with the licence number:  4301051524 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0308390001 . This is a "ADMINASTAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180023697 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180F375320 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180F375320 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0004237942 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3117704 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4237942 . This is a "DETROIT MEDICAL CENTER" identifier . This identifiers is of the category "OTHER".
  • Identifier: C3069 . This is a "MCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101836 . This is a "GREAT LAKES" identifier . This identifiers is of the category "OTHER".
  • Identifier: E89376 . This is a "HAP" identifier . This identifiers is of the category "OTHER".




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