Provider Demographics
NPI:1255440178
Name:LANDIS, KIM C (MD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:C
Last Name:LANDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9319 HARBOR COVE CIR
Mailing Address - Street 2:APT # 112
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-8216
Mailing Address - Country:US
Mailing Address - Phone:248-544-5606
Mailing Address - Fax:
Practice Address - Street 1:24261 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3117
Practice Address - Country:US
Practice Address - Phone:248-569-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052674207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF27533Medicare UPIN