Healthcare Provider Details

I. General information

NPI: 1902253297
Provider Name (Legal Business Name): PHILLIP KUCAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST 9C-UHC
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST 9C-UHC
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301503577
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: