Provider Demographics
NPI:1679579122
Name:OMILUSIK, KEVIN M (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:OMILUSIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:MI
Mailing Address - Zip Code:49635-9658
Mailing Address - Country:US
Mailing Address - Phone:231-352-2990
Mailing Address - Fax:231-835-2534
Practice Address - Street 1:224 PARK AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:MI
Practice Address - Zip Code:49635-9658
Practice Address - Country:US
Practice Address - Phone:231-352-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065619207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services