Provider Demographics
NPI:1891955597
Name:KENNETH DZIUBA MD PC
Entity Type:Organization
Organization Name:KENNETH DZIUBA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIUBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-773-7780
Mailing Address - Street 1:21331 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3265
Mailing Address - Country:US
Mailing Address - Phone:586-773-7780
Mailing Address - Fax:586-774-9656
Practice Address - Street 1:21331 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3265
Practice Address - Country:US
Practice Address - Phone:586-773-7780
Practice Address - Fax:586-774-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010039122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4157965Medicaid
MI0P59280Medicare PIN
MI4157965Medicaid
MI0505614Medicare PIN
MIA74419Medicare UPIN