Provider Demographics
NPI:1679689087
Name:KUTSKILL, KEVIN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:KUTSKILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:35054 23 MILE RD
Mailing Address - Street 2:101
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2019
Mailing Address - Country:US
Mailing Address - Phone:586-725-2670
Mailing Address - Fax:586-725-3347
Practice Address - Street 1:35054 23 MILE RD
Practice Address - Street 2:101
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-2019
Practice Address - Country:US
Practice Address - Phone:586-725-2670
Practice Address - Fax:586-725-3347
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301052707208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2899472Medicaid
MI2899472Medicaid