Healthcare Provider Details

I. General information

NPI: 1104019231
Provider Name (Legal Business Name): ANAS KUTAIT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 HUBBARD DR
DEARBORN MI
48126-2641
US

IV. Provider business mailing address

2799 W. GRAND BLVD
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-8632
  • Fax:
Mailing address:
  • Phone: 313-916-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301088376
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: