Physician Compare National (NPI:1134569395)

HEALTHCARE PROVIDER: JACOB KALLIATH D.O.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1134569395
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	4486947421
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20170119002900
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	KALLIATH
	Individual professional last name
Provider First Name	JACOB
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	NOVA SOUTHEASTERN UNIV COLLEGE OF DENTAL MEDICINE
	Individual professional's medical school
Graduation Year	2013
	Individual professional's medical school graduation year
Primary Specialty	INTERNAL MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	333 E 2ND ST
	Group Practice or individual's line 1 address
City	RICHLAND CENTER
	Group Practice or individual's city
State	WI
	Group Practice or individual's state
Zip Code	535811914
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	140114
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	SWEDISH COVENANT HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	521341
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	RICHLAND HOSPITAL
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y