Provider Demographics
NPI:1720350275
Name:KAHLON SURINDERPAL S
Entity Type:Organization
Organization Name:KAHLON SURINDERPAL S
Other - Org Name:EXAMMD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:SURINDERPAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAHLON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-497-9090
Mailing Address - Street 1:601 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4320
Mailing Address - Country:US
Mailing Address - Phone:217-442-4055
Mailing Address - Fax:425-795-5915
Practice Address - Street 1:601 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4320
Practice Address - Country:US
Practice Address - Phone:217-442-4055
Practice Address - Fax:425-795-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091614261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36137-20OtherLICENSE
IL036091614Medicaid
IL09232010OtherBCBS
IN01058575AOtherLICENSE
204223Medicare PIN
IL09232010OtherBCBS