Provider Demographics
NPI:1467929927
Name:CISCHKE, KEVIN LOUIS (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LOUIS
Last Name:CISCHKE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 HIDDENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-1522
Mailing Address - Country:US
Mailing Address - Phone:734-755-2728
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.416348163WE0003X
OHAPRN.CNP.023948363LF0000X
MI4704341344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704341344OtherSTATE OF MICHIGAN LICENSE