NPIMap

Individual provider Active NPI

Prem Barry Kissoondial, MD

  • Family Medicine Physician
  • Mount Pleasant, MI
National Provider Identifier
1437246451
Registry record updated Dec 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
4301066299 Issued in MI
Practice address
2591 S Leaton Rd
Mount Pleasant, MI 48858-8421
Phone
(989) 775-4600
Fax
(989) 775-4680
NPI assigned
Oct 10, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 6, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 4301066299 MI Primary

Addresses

Primary practice location

2591 S Leaton Rd
Mount Pleasant, MI 48858-8421

Mailing address

2591 S Leaton Rd
Mount Pleasant, MI 48858-8421
Phone (989) 775-4600

Other identifiers 2

IdentifierTypeStateIssuer
010C760120OtherMIBLUE CROSS BLUE SHIELD OF MICHIGAN
1437246451MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20131021000598 MI Practitioner - Family Practice 9032158035 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 1991
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Powerback Rehabilitation LLCGroup PAC ID 2365359932, 600 clinicians
Saginaw Chippewa Indian TribeGroup PAC ID 8820068893, 7 clinicians

Practice addresses (Care Compare)

255 Mayer Rd
Frankenmuth, MI 48734-1358
Phone (989) 349-0016

2591 S Leaton Rd
Mount Pleasant, MI 48858-8421
Phone (989) 775-4600

Hospital & facility affiliations

  • Mymichigan Home Care Home health agency, Midland, MI, CCN 237015
  • Mymichigan Medical Center Clare Hospital, Clare, MI, CCN 230180
  • Saint Mary'S Standish Community Hospital Hospital, Standish, MI, CCN 231305
  • McLaren Central Michigan Hospital, Mount Pleasant, MI, CCN 230080
  • Mymichigan Medical Center Midland Hospital, Midland, MI, CCN 230222

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Saginaw Chippewa Indian Tribe CurrentSince Jul 29, 2013 Accepting new patients
Saginaw Chippewa Indian Tribe CurrentSince Jul 29, 2013 Accepting new patients

Locations

2591 S Leaton Rd
Mt Pleasant, MI 48858
Phone (989) 775-4600

Interoperability endpoints

  • Direct secure messaging: pkissoondial@sagchip.directbygreenway.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701820800000",
    "number": "1437246451",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2591 S LEATON RD",
            "city": "MOUNT PLEASANT",
            "state": "MI",
            "postal_code": "488588421",
            "telephone_number": "989-775-4600",
            "fax_number": "989-775-4680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2591 S LEATON RD",
            "city": "MOUNT PLEASANT",
            "state": "MI",
            "postal_code": "488588421",
            "telephone_number": "989-775-4600",
            "fax_number": "989-775-4680"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KISSOONDIAL",
        "first_name": "PREM",
        "middle_name": "BARRY",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-10",
        "last_updated": "2023-12-06",
        "certification_date": "2023-12-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "4301066299",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD OF MICHIGAN",
            "identifier": "010C760120",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1437246451",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mount Pleasant, MI

Sources for this page

Verify at the official NPI Registry.