Basic Information
Provider Information | |||||||||
NPI: | 1235171158 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUTSCHE | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5900 BYRON CENTER AVE SW | ||||||||
Address2: | MEDICAL ADMINISTRATION | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495199606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162523243 | ||||||||
FaxNumber: | 6162520260 | ||||||||
Practice Location | |||||||||
Address1: | 1787 GRAND RIDGE CT NE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 49525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167748131 | ||||||||
FaxNumber: | 6167748204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 12/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301048845 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2957057 | 05 | MI |   | MEDICAID | 4554094 | 01 | MI | AETNA | OTHER | 900000696 | 01 | MI | PRIORITY HEALTH | OTHER | 080D17690 | 01 | MI | BLUE SHIELD | OTHER |