Provider Demographics
NPI:1508847740
Name:KARTUSH, JACK M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:KARTUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30055 NORTHWESTERN HWY
Mailing Address - Street 2:STE 101
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3230
Mailing Address - Country:US
Mailing Address - Phone:248-865-4444
Mailing Address - Fax:248-865-6161
Practice Address - Street 1:30055 NORTHWESTERN HWY
Practice Address - Street 2:STE 101
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3230
Practice Address - Country:US
Practice Address - Phone:248-865-4444
Practice Address - Fax:248-865-6161
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041062207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3245286Medicaid
MI3245286Medicaid
A79552Medicare UPIN