Provider Demographics
NPI:1922072602
Name:MAKSIMOWICZ-MCKINNON, KATHLEEN M (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:MAKSIMOWICZ-MCKINNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W GRAND BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3141
Mailing Address - Country:US
Mailing Address - Phone:313-916-2631
Mailing Address - Fax:
Practice Address - Street 1:3031 W GRAND BLVD STE 800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3141
Practice Address - Country:US
Practice Address - Phone:313-916-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013023174400000X
MI5101014012207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101007671Medicaid
PA081765E8JMedicare ID - Type Unspecified
PA101007671Medicaid