Healthcare Provider Details

I. General information

NPI: 1720350275
Provider Name (Legal Business Name): KAHLON SURINDERPAL S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N LOGAN AVE
DANVILLE IL
61832-4320
US

IV. Provider business mailing address

601 N LOGAN AVE
DANVILLE IL
61832-4320
US

V. Phone/Fax

Practice location:
  • Phone: 217-442-4055
  • Fax: 425-795-5915
Mailing address:
  • Phone: 217-442-4055
  • Fax: 425-795-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number036091614
License Number StateIL

VIII. Authorized Official

Name: SURINDERPAL S KAHLON
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 217-497-9090