Basic Information
| Provider Information | |||||||||
| NPI: | 1104039072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZETTEK | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT CH 17767 | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600557767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GENESYS PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
| FaxNumber: | 6165327230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101015741 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 5101015741 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | KZ015741 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 5179420 | 05 | MI | MEDICAID | 5179466 | 05 | MI | MEDICAID | P00432452 | 01 | RAILROAD MEDICARE | OTHER | 5179448 | 05 | MI | MEDICAID |