Basic Information
| Provider Information | |||||||||
| NPI: | 1215949060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALAL | ||||||||
| FirstName: | KANU | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | RADIOLOGY DEPT | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109875000 | ||||||||
| FaxNumber: | 8109850032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | RADIOLOGY DEPT | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109875000 | ||||||||
| FaxNumber: | 8109850032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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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 | 2085R0202X | 042934 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X | 4301042934 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | 4301042934 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1947181 | 05 | MI | MEDICAID |