Basic Information
| Provider Information | |||||||||
| NPI: | 1043510183 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KANSAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLATINUM MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153771674 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8733 BEVERLY BLVD STE 306 | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103886798 | ||||||||
| FaxNumber: | 3234004302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/09/2021 | ||||||||
| NPIReactivationDate: | 09/14/2021 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARLAN | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6155776340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.