=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235325226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAISER MEDICAL CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 09/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11670 MARTIN RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-754-3830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11670 MARTIN RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-754-3830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | MADHAVI NONE KANNEGANTI
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 586-754-3830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MK058470
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------