Healthcare Provider Details

I. General information

NPI: 1689682551
Provider Name (Legal Business Name): GANESH C KUDVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE STE 307
JACKSON MI
49201-1850
US

IV. Provider business mailing address

1100 E MICHIGAN AVE STE 307
JACKSON MI
49201-1850
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1594
  • Fax:
Mailing address:
  • Phone: 517-205-1594
  • Fax: 517-205-1540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number108047
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: