Basic Information
| Provider Information | |||||||||
| NPI: | 1992778807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASCHKE | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | SUITE 298 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 3040 BOURN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497568134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897864877 | ||||||||
| FaxNumber: | 9897862187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 4301068537 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0F96004 | 01 | MI | GROUP MEDICARE ID NUMBER | OTHER | 4503518 | 05 | MI | MEDICAID |