Provider Demographics
NPI:1063496867
Name:KALO, GORDON (CRNA)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:KALO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-755-1463
Practice Address - Street 1:200 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9237
Practice Address - Country:US
Practice Address - Phone:989-362-0153
Practice Address - Fax:989-362-4683
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120512367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4096233Medicaid
MIC56007027Medicaid