Healthcare Provider Details

I. General information

NPI: 1912448564
Provider Name (Legal Business Name): MICHAEL KISSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD #4209
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

120 S SWALL DR #102
LOS ANGELES CA
90048-3060
US

V. Phone/Fax

Practice location:
  • Phone: 818-618-3037
  • Fax:
Mailing address:
  • Phone: 818-618-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number135031
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number135031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: