MEDICARE: DANIEL E KISLOV MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	4301042985	MI

General Provider Information

NPI Number	:	1770659872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL E KISLOV MD

Provider Business Mailing Address
First Line	:	1675 LEAHY STREET
Second Line	:	SUITE 328
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5543
Country	:	US
Telephone Number	:	231-727-5565
Fax Number	:	231-727-5568

Provider Business Practice Location Address
First Line	:	1675 LEAHY STREET
Second Line	:	SUITE 328
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5543
Country	:	US
Telephone Number	:	231-727-5565
Fax Number	:	231-727-5568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	02/19/2008

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