Provider Demographics
NPI:1366487761
Name:KNEISER, MARY KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:KNEISER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:22030 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2369
Mailing Address - Country:US
Mailing Address - Phone:586-443-5686
Mailing Address - Fax:586-443-5689
Practice Address - Street 1:22030 MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2369
Practice Address - Country:US
Practice Address - Phone:586-443-5686
Practice Address - Fax:586-443-5689
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301051497208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383581109OtherTAX ID
MI383581109OtherTAX ID