Healthcare Provider Details

I. General information

NPI: 1407084296
Provider Name (Legal Business Name): MONTY REX LYBBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

6071 W OUTER DR
DETROIT MI
48235-2624
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-1020
  • Fax:
Mailing address:
  • Phone: 313-966-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30556
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberQ0966
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: