Provider Demographics
NPI:1437246451
Name:KISSOONDIAL, PREM BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:BARRY
Last Name:KISSOONDIAL
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:2591 S LEATON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8421
Mailing Address - Country:US
Mailing Address - Phone:989-775-4600
Mailing Address - Fax:989-775-4680
Practice Address - Street 1:2591 S LEATON RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-8421
Practice Address - Country:US
Practice Address - Phone:989-775-4600
Practice Address - Fax:989-775-4680
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301066299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010C760120OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI1437246451Medicaid
MI0C76012030Medicare PIN
PA391865Medicare Oscar/Certification