Healthcare Provider Details

I. General information

NPI: 1801295696
Provider Name (Legal Business Name): KS MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE ROBERT WOOD JOHNSON PLACE ROBERT WOOD JOHNSON HOSPITAL
NEW BRUNSWICK NJ
08901-1966
US

IV. Provider business mailing address

5118 SILVER FOX TRL
ROCKFORD IL
61114-7010
US

V. Phone/Fax

Practice location:
  • Phone: 330-289-9891
  • Fax:
Mailing address:
  • Phone: 330-289-9891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KIANOUSH SHEYKHOLESLAMI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 330-289-9891