Healthcare Provider Details

I. General information

NPI: 1780071811
Provider Name (Legal Business Name): KENNETH JEROME MUELLER III D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date: 08/12/2020
Reactivation Date: 08/25/2020

III. Provider practice location address

3240 W CARLETON RD STE B
HILLSDALE MI
49242-9458
US

IV. Provider business mailing address

3240 W CARLETON RD STE B
HILLSDALE MI
49242-9458
US

V. Phone/Fax

Practice location:
  • Phone: 517-610-5469
  • Fax: 517-586-0228
Mailing address:
  • Phone: 517-610-5469
  • Fax: 517-586-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number5101024611
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number5101024611
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: