Basic Information
| Provider Information | |||||||||
| NPI: | 1083614531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALLAL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605225712 | ||||||||
| FaxNumber: | 8605204270 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605225712 | ||||||||
| FaxNumber: | 8605204270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 019484 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 001194844 | 05 | CT | MEDICAID | OS2283 | 01 | CT | HEALTHNET ID# | OTHER | P1236548 | 01 | CT | OXFORD HEALTH ID# | OTHER | 010019484CT01 | 01 | CT | ANTHEM BCBS ID# | OTHER | 13459 | 01 | CT | HEALTH NEW ENGLAND ID# | OTHER | 2266768003 | 01 | CT | CIGNA ID# | OTHER | 2043107 | 01 | CT | AETNA ID# | OTHER | 0521150446 | 01 | CT | CONNECTICARE ID# | OTHER | P12038342 | 01 | CT | MULTIPLAN ID# | OTHER |