Healthcare Provider Details

I. General information

NPI: 1639371263
Provider Name (Legal Business Name): MICHAEL ROBERT KACZANOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 PROSPECT ST NORTH II
NASHUA NH
03060-3925
US

IV. Provider business mailing address

8 PROSPECT ST NORTH II
NASHUA NH
03060-3925
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-5355
  • Fax: 603-577-5356
Mailing address:
  • Phone: 603-577-5355
  • Fax: 603-577-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number13968
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: