Provider Demographics
NPI:1245717909
Name:KUTOM, FADEE (MD)
Entity type:Individual
Prefix:DR
First Name:FADEE
Middle Name:
Last Name:KUTOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-2000
Mailing Address - Fax:810-342-3659
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-342-2000
Practice Address - Fax:810-342-3659
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072953207R00000X
MI4301507051390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK35024189031Medicaid