Provider Demographics
NPI:1841201563
Name:KALLEY, AIDA (MD)
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:KALLEY
Suffix:
Gender:F
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:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:236 CLEARFIELD AVE STE 215
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1893
Practice Address - Country:US
Practice Address - Phone:757-853-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232965207PE0004X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010056233Medicaid
VA005873916Medicaid
VAP00112281Medicare PIN
VAP00049939Medicare PIN
VA010056233Medicaid
VA002393V59Medicare PIN
VA005873916Medicaid