Provider Demographics
NPI:1649329541
Name:CHANDER KANTA
Entity type:Organization
Organization Name:CHANDER KANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-758-3210
Mailing Address - Street 1:26328 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1215
Mailing Address - Country:US
Mailing Address - Phone:586-758-3210
Mailing Address - Fax:586-758-3233
Practice Address - Street 1:26328 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1215
Practice Address - Country:US
Practice Address - Phone:586-758-3210
Practice Address - Fax:586-758-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104509549Medicaid
0N73300Medicare ID - Type UnspecifiedMEDICARE
MI104509549Medicaid