Basic Information
| Provider Information | |||||||||
| NPI: | 1093720815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KULDANEK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 EAGLE PARK DR NE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495254570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164581088 | ||||||||
| FaxNumber: | 6164587809 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168408005 | ||||||||
| FaxNumber: | 6168409642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0010X | 4301041190 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
ID Information
| ID | Type | State | Issuer | Description | RR250010074 | 01 | MI | MEDICARE RR | OTHER | 1403831 | 05 | MI | MEDICAID |