Basic Information
| Provider Information | |||||||||
| NPI: | 1790313856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWIATKOWSKI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST # 56 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5629 STADIUM DR STE B | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490091952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695443270 | ||||||||
| FaxNumber: | 2695443288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2020 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 5302042237 | MI | Y |
No ID Information.