Basic Information
| Provider Information | |||||||||
| NPI: | 1407083595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RESCHKE | ||||||||
| FirstName: | MIKA | ||||||||
| MiddleName: | ALICIA-BROOKS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTHEWS | ||||||||
| OtherFirstName: | MIKA | ||||||||
| OtherMiddleName: | ALICIA-BROOKS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 JOHN ST STE M-515 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417145 | ||||||||
| FaxNumber: | 2693417148 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST STE M-515 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938704 | ||||||||
| FaxNumber: | 6142934063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 4301111572 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.