Basic Information
| Provider Information | |||||||||
| NPI: | 1215056817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALU | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KALU | ||||||||
| OtherFirstName: | UZOMA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 SYCAMORE ST # 329 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477081820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149732511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24760 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 01065819A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | C7-0003225 | DE | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000640362 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 200973010 | 05 | IN | MEDICAID |