Provider Demographics
NPI:1336240225
Name:ANZICEK, KATHLEEN (DO)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:ANZICEK
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:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-0246
Mailing Address - Country:US
Mailing Address - Phone:517-522-8403
Mailing Address - Fax:517-522-4275
Practice Address - Street 1:12337 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-0246
Practice Address - Country:US
Practice Address - Phone:517-522-8403
Practice Address - Fax:517-522-4275
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKA008052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0153800065OtherBLUE CHOICE
015380065OtherBCBS FEP PROGRAM
0153800065OtherBLUE CARE NETWORK
015380065OtherBCBS COMMUNITY BLUE
0153800065OtherBCBS PPO
MI0153800065OtherBLUE CROSS BLUE SHIELD
0153800065OtherBCBS BLUE PREFERRED
MI2126487Medicaid
0153800065OtherBLUE CHOICE
MI5380006Medicare ID - Type Unspecified