Provider Demographics
NPI:1982606414
Name:KISSEL, CHARLES GREGORY (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GREGORY
Last Name:KISSEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29433 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-574-0500
Mailing Address - Fax:586-574-2694
Practice Address - Street 1:29433 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-574-0500
Practice Address - Fax:586-574-2694
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000960213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4949617Medicaid
MI480F330020OtherBCBSM
MI1715614Medicaid
MI480E011810OtherBCBSM
MI2932693Medicaid
MI4585272Medicaid
MIT34053OtherUPIN
MI480F335300OtherBCBSM
MI480Q24567OtherBCBSM
MI5987390001Medicare NSC
MI0Q24567001Medicare PIN
MI0P31990002Medicare PIN
MI480F330020Medicare PIN
MI480017711Medicare PIN
MI480F330020OtherBCBSM
MIT34053OtherUPIN
MI4949617Medicaid