Provider Demographics
NPI:1366480238
Name:KRAEMER, MICHAEL BARTHOLOMEW (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BARTHOLOMEW
Last Name:KRAEMER
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29425 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-755-9340
Mailing Address - Fax:586-755-9341
Practice Address - Street 1:29427 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-755-9340
Practice Address - Fax:586-755-1081
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176571223S0112X
MI2901016237204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0205016472OtherBC MED/SURG PIN
MI970E07680OtherBLUE CROSS PIN
MII37915Medicare UPIN
MI970E07680OtherBLUE CROSS PIN