Basic Information
| Provider Information | |||||||||
| NPI: | 1649764242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTRYKUS | ||||||||
| FirstName: | MONIKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
| Address2: | CHRISTIE BUILDING | ||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486702000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898393500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4611 CAMPUS RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486409533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898393500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301115604 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 4351029584 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.