Provider Demographics
NPI:1093706640
Name:KALENKIEWICZ, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:KALENKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 NORTH MACOMB STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2904
Mailing Address - Country:US
Mailing Address - Phone:734-242-6499
Mailing Address - Fax:734-242-8992
Practice Address - Street 1:730 NORTH MACOMB STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2904
Practice Address - Country:US
Practice Address - Phone:734-242-6499
Practice Address - Fax:734-242-8992
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI4301050330207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301050330OtherMD LICENSE
MI382834187OtherEIN
MI382834187OtherEIN
MIE37208Medicare UPIN
MI101979200Medicaid
MI0580805Medicare PIN
MIP52570007OtherMEDICARE IND PTAN