Provider Demographics
NPI:1881706273
Name:KRUK, MICHAEL (MSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KRUK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HAZEN ST
Mailing Address - Street 2:SUITE L3
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1040
Mailing Address - Country:US
Mailing Address - Phone:269-657-1595
Mailing Address - Fax:269-657-1534
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE L3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-1595
Practice Address - Fax:269-657-1534
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010676481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H060020OtherBCBSM
MIH06012022Medicare PIN
MIOP13330Medicare PIN