Healthcare Provider Details

I. General information

NPI: 1043832801
Provider Name (Legal Business Name): KSK MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 WINTER RD
MANITOU BEACH MI
49253-9634
US

IV. Provider business mailing address

6300 WINTER RD
MANITOU BEACH MI
49253-9634
US

V. Phone/Fax

Practice location:
  • Phone: 517-306-2244
  • Fax: 866-465-0269
Mailing address:
  • Phone: 517-306-2244
  • Fax: 866-465-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBYN M JONES
Title or Position: BUSINESS MANAGER
Credential:
Phone: 517-306-2244