Provider Demographics
NPI:1568420305
Name:DUTCHESHEN, NICHOLAS THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:THOMAS
Last Name:DUTCHESHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
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:248-244-9495
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:248-244-9495
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077647207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5223466Medicaid
MI5223466Medicaid