Provider Demographics
NPI:1437544012
Name:NICHOLAS DUTCHESHEN
Entity Type:Organization
Organization Name:NICHOLAS DUTCHESHEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTCHESHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-244-9426
Mailing Address - Street 1:1350 KIRTS BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4851
Mailing Address - Country:US
Mailing Address - Phone:248-244-9426
Mailing Address - Fax:
Practice Address - Street 1:1350 KIRTS BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4851
Practice Address - Country:US
Practice Address - Phone:248-244-9426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077647207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5223466Medicaid
0P46590Medicare PIN