Provider Demographics
NPI:1043498652
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:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:KISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
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:2008-02-06
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK000960213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5137446OtherFIRST HEALTH
MI480F335300OtherBCBSM
MI4949617Medicaid
MI5987390001OtherDME
MI12268OtherM-CARE
MI21171OtherOMNI
MI2559787OtherCIGNA
MI480Q245670OtherBCBSM
MI1715614Medicaid
MI480017711OtherMCRR
MI5972192OtherAETNA
MI6087740001OtherDME
MIP44714OtherB PLUS
MI480017380OtherMCRR
MIP00422721OtherMCRR
MI480E011810OtherBCBSM
MI12268OtherM-CARE
MI21171OtherOMNI
MI480F335300OtherBCBSM
MI5972192OtherAETNA