Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 31457 | KY |
Y | 2080P0204X | Pediatric Emergency Doctor | 31457 | KY |
NPI | 1083685317 |
---|---|
Provider Name | Dr. Jean Marie Kallis |
First Address | Chicago, IL 60677-6879 |
Second Address | Louisville, KY 40202-1821 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2006 |
Last Update Date | 08/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200012490 | (05) | IN |
64937543 | (05) | KY |
F92656 | (02) |