Provider Demographics
NPI:1013001221
Name:CHARLES G KISSEL DPM PC
Entity Type:Organization
Organization Name:CHARLES G KISSEL DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-574-0500
Mailing Address - Street 1:29433 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-574-0500
Mailing Address - Fax:586-574-2694
Practice Address - Street 1:29433 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-574-0500
Practice Address - Fax:586-574-2694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK000960213ES0103X, 332B00000X
MIZH002007213ES0103X
MIMS00843213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI134865123Medicaid
MI480017711OtherMCRR
MI480E011810OtherBCBS
MI480E011810OtherBCN
MIZH002007OtherLICENSE
MI540E026180OtherBCDME
MI5901002214OtherLICENSE
MICK000960OtherLICENSE
MIMS000843OtherLICENSE
MI540E026180OtherBCDME
MI480E011810OtherBCBS