Basic Information
| Provider Information | |||||||||
| NPI: | 1710089453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KACZKOFSKY | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | EARL DAVID | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 2221 HEALTH DR SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162524410 | ||||||||
| FaxNumber: | 6162524480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 012006 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1654101584 | 01 | MI | BLUE CARE NETWORD | OTHER | 4708195 | 05 | MI | MEDICAID | 4708275 | 05 | MI | MEDICAID | 4708005 | 05 | MI | MEDICAID | 1654101584 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 4708168 | 05 | MI | MEDICAID |