Provider Demographics
NPI:1164486940
Name:SUTKAMP, MICHAEL W (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:SUTKAMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:4002 KRESGE WAY
Practice Address - Street 2:STE 124
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4661
Practice Address - Country:US
Practice Address - Phone:502-238-2801
Practice Address - Fax:502-238-2835
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY30310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000350550OtherANTHEM - NMA
1193585OtherCHA / NMA
KY2434332000OtherPASSPORT ADVANTAGE - NMA
KY64303100Medicaid
KY1063095OtherPASSPORT - NMA
000052155EOtherHUMANA / NMA
KY009110OtherSIHO - NMA
2540713001OtherCIGNA / NMA
KYP00176908OtherRAILROAD MEDICARE
KYF59396Medicare UPIN
KY64303100Medicaid