Provider Demographics
NPI:1518189463
Name:KUTZ, MEGHAN MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:MARIA
Last Name:KUTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-1631
Mailing Address - Country:US
Mailing Address - Phone:715-685-6600
Mailing Address - Fax:715-685-6601
Practice Address - Street 1:415 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1631
Practice Address - Country:US
Practice Address - Phone:715-685-6600
Practice Address - Fax:715-685-6601
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1518189463OtherMEDICA
MN17P84KUOtherBCBS
MN956480000Medicaid
P00438364OtherRR MEDICARE PTAN
MN080016163Medicare PIN