Healthcare Provider Details

I. General information

NPI: 1790047918
Provider Name (Legal Business Name): KYLE D. KUTSCHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 FARR RD
FRUITPORT MI
49415-8779
US

IV. Provider business mailing address

3443 FARR RD
FRUITPORT MI
49415-8779
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-2900
  • Fax: 231-672-2901
Mailing address:
  • Phone: 231-672-2900
  • Fax: 231-672-2901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27602
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101264969
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301506248
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: