Healthcare Provider Details

I. General information

NPI: 1467974535
Provider Name (Legal Business Name): KERRYN ASHLEIGH ROOME MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E HOSPITAL DRIVE CW 11-715Z, SPC 4204
ANN ARBOR MI
48109-4204
US

IV. Provider business mailing address

1540 E HOSPITAL DRIVE CW 11-715Z, SPC 4204
ANN ARBOR MI
48109-4204
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-4038
  • Fax:
Mailing address:
  • Phone: 734-936-4038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML61160489
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD61522171
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4351053771
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: