Provider Demographics
NPI:1083983498
Name:KIDNEY CENTER OF MICHIGAN
Entity Type:Organization
Organization Name:KIDNEY CENTER OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAKULAVARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-858-3011
Mailing Address - Street 1:PO BOX 71026
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-0019
Mailing Address - Country:US
Mailing Address - Phone:248-858-3011
Mailing Address - Fax:800-414-1646
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:248-858-3011
Practice Address - Fax:800-414-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084121207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301084121OtherLICENSE