Basic Information
| Provider Information | |||||||||
| NPI: | 1700841541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALLGREN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 E MISSOURI AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 E MISSOURI AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD18182 | OR | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 19539 | AZ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | MD18182 | OR | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 19539 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 806093700 | 05 | ID | MEDICAID | 050039034 | 01 | OR | RR MEDICARE | OTHER | 070040 | 05 | OR | MEDICAID | 8170268 | 05 | WA | MEDICAID | XPY183725 | 05 | CA | MEDICAID |