Provider Demographics
NPI:1104181692
Name:J.K.KANSAL MD PC
Entity Type:Organization
Organization Name:J.K.KANSAL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JATINDER
Authorized Official - Middle Name:K
Authorized Official - Last Name:KANSAL
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:219-769-7761
Mailing Address - Street 1:8969 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7039
Mailing Address - Country:US
Mailing Address - Phone:219-769-7761
Mailing Address - Fax:219-769-0895
Practice Address - Street 1:8969 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7039
Practice Address - Country:US
Practice Address - Phone:219-769-7761
Practice Address - Fax:219-769-0895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032298B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100169090BMedicaid
IN498490Medicare PIN
INB29111Medicare UPIN