Provider Demographics
NPI:1154512804
Name:K KAPORDELIS MD PLLC
Entity Type:Organization
Organization Name:K KAPORDELIS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MA
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-779-9899
Mailing Address - Street 1:21421 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3215
Mailing Address - Country:US
Mailing Address - Phone:586-779-9899
Mailing Address - Fax:586-773-7800
Practice Address - Street 1:21421 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3215
Practice Address - Country:US
Practice Address - Phone:586-779-9899
Practice Address - Fax:586-773-7800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI041225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4690260Medicaid
MIA78052Medicare UPIN