Healthcare Provider Details

I. General information

NPI: 1104865476
Provider Name (Legal Business Name): JASON BERNARD JAMES KUREK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 WEST 9 MILE RD SUITE 340
SOUTHFIELD MI
48075
US

IV. Provider business mailing address

17515 W 9 MILE RD SUITE 340
SOUTHFIELD MI
48075-4403
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-4000
  • Fax: 248-569-5771
Mailing address:
  • Phone: 248-569-4000
  • Fax: 248-569-5771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001753
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number5901001753
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: