Provider Demographics
NPI:1083685317
Name:KALLIS, JEAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE
Last Name:KALLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:OGBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-629-6000
Practice Address - Fax:502-629-5991
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31457208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64937543Medicaid
IN200012490Medicaid
IN200012490Medicaid
KYK018640Medicare PIN
KYK018641Medicare PIN