Basic Information
| Provider Information | |||||||||
| NPI: | 1700897048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALASSIAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664943 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2152144044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | ME108047 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 051669 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 51977 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME108047 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 051669 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | MD073250L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 51977 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 14E0T | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 003664000 | 05 | FL | MEDICAID | FC156W | 01 | FL | MEDICARE TIN | OTHER | 519772 | 05 | SC | MEDICAID |