Basic Information
| Provider Information | |||||||||
| NPI: | 1164486940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTKAMP | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895753 | ||||||||
| Practice Location | |||||||||
| Address1: | 4002 KRESGE WAY | ||||||||
| Address2: | STE 124 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022382801 | ||||||||
| FaxNumber: | 5022382835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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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 | 207R00000X | 30310 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000350550 | 01 | KY | ANTHEM - NMA | OTHER | 1193585 | 01 | CHA / NMA | OTHER | 2434332000 | 01 | KY | PASSPORT ADVANTAGE - NMA | OTHER | 64303100 | 05 | KY | MEDICAID | 1063095 | 01 | KY | PASSPORT - NMA | OTHER | 000052155E | 01 | HUMANA / NMA | OTHER | 009110 | 01 | KY | SIHO - NMA | OTHER | 2540713001 | 01 | CIGNA / NMA | OTHER | P00176908 | 01 | KY | RAILROAD MEDICARE | OTHER |