Provider Demographics
NPI:1306830963
Name:KINACHTCHOUK, NIKOLAI (MD)
Entity Type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:
Last Name:KINACHTCHOUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 TOWNE CTR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2818
Mailing Address - Country:US
Mailing Address - Phone:989-790-2984
Mailing Address - Fax:989-790-2983
Practice Address - Street 1:4705 TOWNE CTR
Practice Address - Street 2:SUITE 102
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-790-2984
Practice Address - Fax:989-790-2983
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINK065669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4564863Medicaid
MIG89713Medicare UPIN
MI4564863Medicaid