Provider Demographics
NPI:1093999385
Name:KALAKISH, SAMER RIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMER
Middle Name:RIDA
Last Name:KALAKISH
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-780-0498
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1759
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-780-0498
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121876208800000X
KY42866208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000627329OtherANTHEM
KY7100085210Medicaid
KYP00793920OtherMEDICARE RAILROAD
KY000000627329OtherANTHEM
KY1307452Medicare PIN