Provider Demographics
NPI:1770902900
Name:RAOUF A KAYALEH MD PROF MEDICAL CORP
Entity type:Organization
Organization Name:RAOUF A KAYALEH MD PROF MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAOUF
Authorized Official - Middle Name:ANTOINE
Authorized Official - Last Name:KAYALEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-279-0711
Mailing Address - Street 1:1125 E 17TH ST
Mailing Address - Street 2:SUITE E-109
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2201
Mailing Address - Country:US
Mailing Address - Phone:909-374-0804
Mailing Address - Fax:
Practice Address - Street 1:1125 E 17TH ST
Practice Address - Street 2:SUITE E-109
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2201
Practice Address - Country:US
Practice Address - Phone:909-374-0804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41449207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C414491Medicaid
CAC41449Medicare PIN