Provider Demographics
NPI:1437169034
Name:KORDISH, THERESA A (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:KORDISH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:KORDISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:5513 STONEYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008
Mailing Address - Country:US
Mailing Address - Phone:269-372-3093
Mailing Address - Fax:269-372-0799
Practice Address - Street 1:2121 HUDSON AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-226-0163
Practice Address - Fax:269-226-0171
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010304207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3167232Medicaid
MI1437169034Medicaid
MI5390035OtherBCBS
MI1437169034Medicaid
MIMI609041Medicare PIN
MI3167232Medicaid