Provider Demographics
NPI:1780649921
Name:KULIS, ELEANOR JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:JUDITH
Last Name:KULIS
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:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:586-445-8500
Mailing Address - Fax:586-445-8770
Practice Address - Street 1:29856 SCHOENHERR RD
Practice Address - Street 2:STE III
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088
Practice Address - Country:US
Practice Address - Phone:586-445-8500
Practice Address - Fax:586-445-8770
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430105527602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4125729Medicaid
F34910Medicare UPIN
MI0M83930Medicare ID - Type Unspecified