Basic Information
| Provider Information | |||||||||
| NPI: | 1194806570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUTCHER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8273 GRAND RIVER RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105226080 | ||||||||
| FaxNumber: | 8105226447 | ||||||||
| Practice Location | |||||||||
| Address1: | 8273 GRAND RIVER RD 210 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 2084N0400X | 4301073973 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0010X | 4301073973 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4417296 | 05 | MI | MEDICAID |