Healthcare Provider Details

I. General information

NPI: 1700872116
Provider Name (Legal Business Name): JEFFREY I KALISH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 NOAH DRIVE SUITE 113-315
JASPER GA
30143
US

IV. Provider business mailing address

744 NOAH DR SUITE 113-315
JASPER GA
30143-8705
US

V. Phone/Fax

Practice location:
  • Phone: 706-301-1098
  • Fax: 706-301-9151
Mailing address:
  • Phone: 706-301-1098
  • Fax: 706-301-9151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101-0031149
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1724492
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number147022
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3099A
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number048622-23-11
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: