1417057456 NPI number — LISA KUTAS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417057456 NPI number — LISA KUTAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUTAS
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417057456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR
Provider Second Line Business Mailing Address:
PO BOX 0446 LOBBY J
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-747-6766
Provider Business Mailing Address Fax Number:
734-747-8605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5333 MCAULEY DR
Provider Second Line Business Practice Location Address:
6109
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-712-1300
Provider Business Practice Location Address Fax Number:
734-712-1330
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301081281 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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