Basic Information
| Provider Information | |||||||||
| NPI: | 1619099389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUSLIKIS | ||||||||
| FirstName: | BENEDICT | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166439143 | ||||||||
| FaxNumber: | 6167747699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495062921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167747857 | ||||||||
| FaxNumber: | 6167745487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 247ZC0005X | Y | Technologists, Technicians & Other Technical Service Providers | Pathology | Clinical Laboratory Director, Non-physician |
No ID Information.