Provider Demographics
NPI:1407900681
Name:MARK A KALLUS MD PC
Entity Type:Organization
Organization Name:MARK A KALLUS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KALLUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-278-8871
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-0307
Mailing Address - Country:US
Mailing Address - Phone:517-278-8871
Mailing Address - Fax:517-278-6053
Practice Address - Street 1:360 E CHICAGO ST
Practice Address - Street 2:SUITE 111
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2086
Practice Address - Country:US
Practice Address - Phone:517-278-8871
Practice Address - Fax:517-278-6053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4396777Medicaid
MI4396777Medicaid
MI0N94620Medicare ID - Type Unspecified