Basic Information
| Provider Information | |||||||||
| NPI: | 1316964398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAL | ||||||||
| FirstName: | KIRSHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621305 | ||||||||
| FaxNumber: | 9375227513 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 PHILADELPHIA DR | ||||||||
| Address2: | STE 441 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377344690 | ||||||||
| FaxNumber: | 9375674186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01061017A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35.092771 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 35.092771 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2914510 | 05 | OH | MEDICAID |