Provider Demographics
NPI:1922067461
Name:HYDE, KRISTINA L (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:HYDE
Suffix:
Gender:F
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 1:26901 BEAUMONT BLVD STE 3D400FSC
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:248-552-0307
Practice Address - Street 1:1949 W 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1868
Practice Address - Country:US
Practice Address - Phone:248-551-0615
Practice Address - Fax:248-551-1245
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050403207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110F376980OtherBCBSM
MI1823765Medicaid
MI110F376980OtherBCBSM
MI0N74270003Medicare ID - Type Unspecified