Provider Demographics
NPI:1952455610
Name:HARRY A KEZELIAN JR D P M P C
Entity Type:Organization
Organization Name:HARRY A KEZELIAN JR D P M P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:ALGER
Authorized Official - Last Name:KEZELIAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-354-0057
Mailing Address - Street 1:29877 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1332
Mailing Address - Country:US
Mailing Address - Phone:248-354-0057
Mailing Address - Fax:248-723-8807
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 1012
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-831-6442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001098213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3113830Medicaid
MI3113830Medicaid
MI5051600002Medicare NSC
MI0M09610Medicare PIN