Healthcare Provider Details

I. General information

NPI: 1083983498
Provider Name (Legal Business Name): KIDNEY CENTER OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44555 WOODWARD AVE SUITE 404
PONTIAC MI
48341-5031
US

IV. Provider business mailing address

PO BOX 71026
ROCHESTER HILLS MI
48307-0019
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-3011
  • Fax: 800-414-1646
Mailing address:
  • Phone: 248-858-3011
  • Fax: 800-414-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301084121
License Number StateMI

VIII. Authorized Official

Name: AMITH KAKULAVARAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 248-858-3011