Provider Demographics
NPI:1700897048
Name:KALASSIAN, KENNETH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:KALASSIAN
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-214-4044
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108047207RC0200X, 207RP1001X
GA051669207RC0200X, 207RP1001X
SC51977207RC0200X, 207RP1001X
PAMD073250L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14E0TOtherBLUE CROSS BLUE SHIELD
FL003664000Medicaid
FLFC156WOtherMEDICARE TIN
SC519772Medicaid
FLFC156QMedicare PIN
FL003664000Medicaid