Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 5101013761 | MI |
NPI | 1538189154 |
---|---|
Provider Name | Dr. Kevin L Gietzen |
First Address | Petoskey, MI 49770-2275 |
Second Address | Petoskey, MI 49770-2275 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 24/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0452410245 | BLUE CROSS BLUE SHIELD (01) | MI |
4523065 | (05) | MI |
H91337 | (02) | MI |