Provider Demographics
NPI:1093720815
Name:KULDANEK, ANDREA S (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:S
Last Name:KULDANEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 EAGLE PARK DR NE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4570
Mailing Address - Country:US
Mailing Address - Phone:616-458-1088
Mailing Address - Fax:616-458-7809
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8005
Practice Address - Fax:616-840-9642
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010411902081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRR250010074OtherMEDICARE RR
MI1403831Medicaid
MIA78985Medicare UPIN
MI0D160685252Medicare ID - Type Unspecified