Provider Demographics
NPI:1124231394
Name:JOHN KITZMILLER
Entity Type:Organization
Organization Name:JOHN KITZMILLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KITZMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-551-8400
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:SUITE 248
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6710
Mailing Address - Country:US
Mailing Address - Phone:248-551-8400
Mailing Address - Fax:
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 248
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036695174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB45980Medicare UPIN
MI0N11930Medicare ID - Type Unspecified