Doctor Name: | KYLE EDWARD ANTOSIEK |
NPI Number: | 1376926972 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | D.O. |
License Number: | 5101022121 |
Business Practice Address: | 12000 E 12 Mile Rd Warren, MI - 480933570 |
Business Phone Number: | 5865764140 |
Business Fax Number: | 5865734146 |
Mailing Address: | 12000 E 12 Mile Rd, WARREN |
State: | MI |
Postal Code: | 480933570 |
Phone Number: | 5865764140 |
Fax Number: | 5865734146 |
NPI Enumeration Date: | 07/01/2015 |
NPI Last Update Date: | 07/01/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 5101022121 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |