Provider Demographics
NPI:1609009984
Name:ZACHARY KANJUPARAMBAN MDPC
Entity Type:Organization
Organization Name:ZACHARY KANJUPARAMBAN MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-772-1989
Mailing Address - Street 1:211 S CRAPO ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2961
Mailing Address - Country:US
Mailing Address - Phone:989-772-1989
Mailing Address - Fax:989-772-5523
Practice Address - Street 1:211 S CRAPO ST
Practice Address - Street 2:SUITE D
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2961
Practice Address - Country:US
Practice Address - Phone:989-772-1989
Practice Address - Fax:989-772-5523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1425759Medicaid
MI1425759Medicaid
MI0371766Medicare PIN