Healthcare Provider Details

I. General information

NPI: 1306370333
Provider Name (Legal Business Name): TYLER KUPCHICK D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

IV. Provider business mailing address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1431
  • Fax:
Mailing address:
  • Phone: 517-205-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101025550
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: