Basic Information
| Provider Information | |||||||||
| NPI: | 1194793133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANG | ||||||||
| FirstName: | KAN | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | HENRY FORD HEALTH SYSTEM | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162417 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162417 | ||||||||
| FaxNumber: | 3139168416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301088088 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 4301088088 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | KF088088 | 01 | CHAMPUS-CHAMPUS | OTHER | 060H264410 | 01 | BLUE CROSS-BLUE CROSS | OTHER | KF088088 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 488417410 | 05 | MI | MEDICAID |