Provider Demographics
NPI:1700872116
Name:KALISH, JEFFREY I (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:I
Last Name:KALISH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 NOAH DR
Mailing Address - Street 2:SUITE 113-315
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-8705
Mailing Address - Country:US
Mailing Address - Phone:706-301-1098
Mailing Address - Fax:706-301-9151
Practice Address - Street 1:744 NOAH DRIVE
Practice Address - Street 2:SUITE 113-315
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-301-1098
Practice Address - Fax:706-301-9151
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0031149367500000X
FL1724492367500000X
GA147022367500000X
KY3099A367500000X
NH048622-23-11367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011062Medicaid
GA995335579KMedicaid
NH30342515Medicaid
FL3050611 00Medicaid
NHRE6267Medicare ID - Type Unspecified
NH30342515Medicaid
VT1011062Medicaid