Provider Demographics
NPI:1528296373
Name:MICHALCZYK, KATHRYN ELAINE (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELAINE
Last Name:MICHALCZYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6464
Mailing Address - Country:US
Mailing Address - Phone:574-534-8200
Mailing Address - Fax:574-534-0411
Practice Address - Street 1:1811 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-534-8200
Practice Address - Fax:574-534-0411
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11015152A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201023990Medicaid
INM400073150Medicare PIN