Provider Demographics
NPI:1962467621
Name:KUSHNER, ROGER MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:MATTHEW
Last Name:KUSHNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20276 MIDDLEBELT ROAD SUITE 2
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2054
Mailing Address - Country:US
Mailing Address - Phone:248-476-4900
Mailing Address - Fax:248-476-5435
Practice Address - Street 1:20276 MIDDLEBELT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2054
Practice Address - Country:US
Practice Address - Phone:248-476-4900
Practice Address - Fax:248-476-5435
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006358207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160H261380OtherBCBS/BCN
MI47523OtherOMNI
MIE26610OtherHEALTH ALLIANCE PLAN
MI4033701OtherAETNA
MI110978OtherCARE CHOICES
MI4372550Medicaid
MI160H261380OtherBCBS/BCN
MI4372550Medicaid
MI160H261380OtherBCBS/BCN
MI4033701OtherAETNA