Healthcare Provider Details

I. General information

NPI: 1043498652
Provider Name (Legal Business Name): CHARLES G KISSEL DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29433 RYAN RD
WARREN MI
48092-2203
US

IV. Provider business mailing address

29433 RYAN RD
WARREN MI
48092-2203
US

V. Phone/Fax

Practice location:
  • Phone: 586-574-0500
  • Fax: 586-574-2694
Mailing address:
  • Phone: 586-574-0500
  • Fax: 586-574-2694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberCK000960
License Number StateMI

VIII. Authorized Official

Name: CHARLES G KISSEL
Title or Position: PARTNER
Credential: DPM
Phone: 586-574-0500