Provider Demographics
NPI:1336116235
Name:KAMIENECKI, RUTH ROSA (DO)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ROSA
Last Name:KAMIENECKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1862
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:44130 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2614
Practice Address - Country:US
Practice Address - Phone:248-380-8811
Practice Address - Fax:248-380-3120
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OM08220001Medicare ID - Type Unspecified
E26614Medicare UPIN