Provider Demographics
NPI:1104905306
Name:WILLIAM KALICHMAN MD PLLC
Entity type:Organization
Organization Name:WILLIAM KALICHMAN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MITZI
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-628-2843
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8650
Mailing Address - Country:US
Mailing Address - Phone:509-628-2843
Mailing Address - Fax:509-628-3843
Practice Address - Street 1:560 GAGE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-8650
Practice Address - Country:US
Practice Address - Phone:509-628-2843
Practice Address - Fax:509-628-3843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046273207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1123199Medicaid
WAF83342Medicare UPIN