Provider Demographics
NPI:1376709337
Name:KENNETH H MARKIEWICZ DO PC
Entity Type:Organization
Organization Name:KENNETH H MARKIEWICZ DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:MARKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-285-3733
Mailing Address - Street 1:2323 E PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2414
Mailing Address - Country:US
Mailing Address - Phone:616-285-3733
Mailing Address - Fax:616-285-5960
Practice Address - Street 1:2323 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2414
Practice Address - Country:US
Practice Address - Phone:616-285-3733
Practice Address - Fax:616-285-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1642877Medicaid
MI0454111024OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0454111024OtherBLUE CROSS BLUE SHIELD OF MICHIGAN