Basic Information
Provider Information | |||||||||
NPI: | 1265498745 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAHLOON | ||||||||
FirstName: | MANSHA | ||||||||
MiddleName: | U | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ULLAH | ||||||||
OtherFirstName: | MANSHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 234 MEDICAL CIR | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067802374 | ||||||||
Practice Location | |||||||||
Address1: | 234 MEDICAL CIR | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067802374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 03/11/2015 | ||||||||
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 | 207RI0011X | 37690 | KY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 37690 | KY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 37690 | 01 | KY | LICENSE | OTHER | 64066723 | 05 | KY |   | MEDICAID |