Basic Information
| Provider Information | |||||||||
| NPI: | 1801886049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KULCZYCKI-MITTAG | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KULCZUCKI | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1701 SOUTH BLVD E | ||||||||
| Address2: | STE 290 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483076122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489977900 | ||||||||
| FaxNumber: | 2489977918 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 SOUTH BLVD E | ||||||||
| Address2: | STE 290 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483076122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489977900 | ||||||||
| FaxNumber: | 2489977918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301067684 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110F324370 | 01 | MI | BCBSM | OTHER | DR500669 | 01 | MI | MCARE | OTHER | 104228109 | 05 | MI | MEDICAID |