Provider Demographics
NPI:1548244742
Name:KUSHNER, RICHARD I (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:I
Last Name:KUSHNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25241 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1404
Mailing Address - Country:US
Mailing Address - Phone:313-538-3800
Mailing Address - Fax:313-538-3088
Practice Address - Street 1:25241 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1404
Practice Address - Country:US
Practice Address - Phone:313-538-3800
Practice Address - Fax:313-538-3088
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548244742Medicaid
MIP00206162OtherRR MEDICARE
MI700H217350OtherBLUE SHIELD
MI0M92440124Medicare PIN
MI0Q26332Medicare ID - Type Unspecified
MIP00206162OtherRR MEDICARE