Healthcare Provider Details

I. General information

NPI: 1114955838
Provider Name (Legal Business Name): ANTHONY L KUDIRKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HARRINGTON ST
MOUNT CLEMENS MI
48043-2920
US

IV. Provider business mailing address

PO BOX 1108 ATTN: BARB SIMMONS
ANN ARBOR MI
48106-1108
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-8098
  • Fax: 586-493-8706
Mailing address:
  • Phone: 734-677-7400
  • Fax: 734-677-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301050082
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: