Provider Demographics
NPI:1275757312
Name:PAYSON, KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PAYSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5449 AVALON CT
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2081
Mailing Address - Country:US
Mailing Address - Phone:248-357-3569
Mailing Address - Fax:
Practice Address - Street 1:5449 AVALON CT
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2081
Practice Address - Country:US
Practice Address - Phone:248-357-3569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704205189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION73920Medicare ID - Type Unspecified
MIP51276Medicare UPIN