Healthcare Provider Details

I. General information

NPI: 1215949060
Provider Name (Legal Business Name): KANU B DALAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE RADIOLOGY DEPT
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

1221 PINE GROVE AVE RADIOLOGY DEPT
PORT HURON MI
48060-3511
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5000
  • Fax: 810-985-0032
Mailing address:
  • Phone: 810-987-5000
  • Fax: 810-985-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number042934
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number4301042934
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4301042934
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: