Healthcare Provider Details

I. General information

NPI: 1093720815
Provider Name (Legal Business Name): ANDREA S KULDANEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

3350 EAGLE PARK DR NE SUITE 108
GRAND RAPIDS MI
49525-4570
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8005
  • Fax: 616-840-9642
Mailing address:
  • Phone: 616-458-1088
  • Fax: 616-458-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number4301041190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: