Provider Demographics
NPI:1801886049
Name:KULCZYCKI-MITTAG, ANNA V (MD)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:V
Last Name:KULCZYCKI-MITTAG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:V
Other - Last Name:KULCZUCKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1701 SOUTH BLVD E
Mailing Address - Street 2:STE 290
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6122
Mailing Address - Country:US
Mailing Address - Phone:248-997-7900
Mailing Address - Fax:248-997-7918
Practice Address - Street 1:1701 SOUTH BLVD E
Practice Address - Street 2:STE 290
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-997-7900
Practice Address - Fax:248-997-7918
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067684207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110F324370OtherBCBSM
MIDR500669OtherMCARE
MI104228109Medicaid
MI110F324370OtherBCBSM
MION37740003Medicare ID - Type Unspecified