Basic Information
| Provider Information | |||||||||
| NPI: | 1003249301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KROM | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 39 BROADWAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100063003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124401943 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39 BROADWAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124401943 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2013 | ||||||||
| LastUpdateDate: | 06/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS15744 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PH0002X | 293148 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | 207PH0002X | OS15744 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | 390200000X | 293148 | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 293148 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05242228 | 05 | NY | MEDICAID |