Basic Information
| Provider Information | |||||||||
| NPI: | 1669479846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867512072 | ||||||||
| FaxNumber: | 5867511302 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867512072 | ||||||||
| FaxNumber: | 5867511302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 02/16/2015 | ||||||||
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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 | 207RH0003X | 4301024231 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 700H273300 | 01 | MI | BCBSM | OTHER | 1672544 | 05 | MI | MEDICAID | KT024231 | 01 | MI | BCBSM OTHER IDENTIFIER | OTHER |