Provider Demographics
NPI:1447596267
Name:GREGORY A. KULDANEK P.C.
Entity type:Organization
Organization Name:GREGORY A. KULDANEK P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KULDANEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-822-1821
Mailing Address - Street 1:185 MARYLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3935
Mailing Address - Country:US
Mailing Address - Phone:616-307-6060
Mailing Address - Fax:
Practice Address - Street 1:2320 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5906
Practice Address - Country:US
Practice Address - Phone:616-949-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty