Provider Demographics
NPI:1235325226
Name:KAISER MEDICAL CENTER PC
Entity type:Organization
Organization Name:KAISER MEDICAL CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MADHAVI
Authorized Official - Middle Name:NONE
Authorized Official - Last Name:KANNEGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-754-3830
Mailing Address - Street 1:11670 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4511
Mailing Address - Country:US
Mailing Address - Phone:586-754-3830
Mailing Address - Fax:
Practice Address - Street 1:11670 MARTIN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4511
Practice Address - Country:US
Practice Address - Phone:586-754-3830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK058470363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty