Provider Demographics
NPI:1063680585
Name:DANIEL E KISLOV, M.D.
Entity type:Organization
Organization Name:DANIEL E KISLOV, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KISLOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-727-5565
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:SUITE 328
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-727-5565
Mailing Address - Fax:231-727-5568
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:SUITE 328
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-727-5565
Practice Address - Fax:231-727-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1697919Medicaid
MI2406108272OtherBSBCM
MI1697919Medicaid