Basic Information
| Provider Information | |||||||||
| NPI: | 1366437576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALLINS | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 75TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417611998 | ||||||||
| FaxNumber: | 9417488484 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 MANATEE AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342051719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417488383 | ||||||||
| FaxNumber: | 9417488484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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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 | 208100000X | ME40567 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | ME40567 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 068398100 | 05 | FL | MEDICAID |