Basic Information
| Provider Information | |||||||||
| NPI: | 1225039902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUCHERA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217584 | ||||||||
| FaxNumber: | 3179572705 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 COLD SPRING RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462221960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179556279 | ||||||||
| FaxNumber: | 3179556287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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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 | 204D00000X | OS0501240 | PA | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 204D00000X | 02004171A | IN | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 201158610 | 05 | IN | MEDICAID | P01424414 | 01 | IN | RAIL ROAD PTAN | OTHER | 001929497 | 05 | PA | MEDICAID |