Provider Demographics
NPI:1366402075
Name:KRUG, ERNEST
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:KRUG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:400-FSC/PCS
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1695 W 12 MILE RD
Practice Address - Street 2:STE. 120
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2182
Practice Address - Country:US
Practice Address - Phone:248-691-4744
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010609392080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2929992Medicaid
MI3506314650OtherBCBSM
MID17567Medicare UPIN