Provider Demographics
NPI:1043209596
Name:KALLAY, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KALLAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-721-4390
Mailing Address - Fax:910-721-4399
Practice Address - Street 1:512 VILLAGE RD STE 101
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3409
Practice Address - Country:US
Practice Address - Phone:910-721-4390
Practice Address - Fax:910-721-4399
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231050207RP1001X
NC9700305207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5857091Medicaid
290000273Medicare ID - Type Unspecified
VA5857091Medicaid
290000273Medicare PIN