Provider Demographics
NPI:1467651612
Name:TO, KATHLEEN B (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:TO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:TO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:KATHLEEN TO
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP F
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5332
Practice Address - Country:US
Practice Address - Phone:734-936-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099480208600000X, 2086S0102X
CAA89279208600000X
MO20090086792086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89279OtherCA LICENSE