Provider Demographics
NPI:1588056147
Name:KALISH, MIRANDA (PA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KALISH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:BOECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5368
Mailing Address - Country:US
Mailing Address - Phone:618-235-8720
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-235-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005407363AM0700X
ARPA-799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical