Provider Demographics
NPI:1215243340
Name:ALLAN G KAVALICH MD INC
Entity type:Organization
Organization Name:ALLAN G KAVALICH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KAVALICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-381-1595
Mailing Address - Street 1:1500 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5111
Mailing Address - Country:US
Mailing Address - Phone:909-381-1595
Mailing Address - Fax:909-381-3291
Practice Address - Street 1:1500 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5111
Practice Address - Country:US
Practice Address - Phone:909-381-1595
Practice Address - Fax:909-381-3291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29326207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293260Medicaid
CA00G293260Medicaid