Healthcare Provider Details

I. General information

NPI: 1659421402
Provider Name (Legal Business Name): KEVIN MARTIN GELTZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

5839 COTTONWOOD DR
YPSILANTI MI
48197-8202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-3328
  • Fax:
Mailing address:
  • Phone: 734-528-3090
  • Fax: 313-577-5467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: