Healthcare Provider Details

I. General information

NPI: 1396195863
Provider Name (Legal Business Name): KYLE BRONSTEEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date: 06/03/2020
Reactivation Date: 06/09/2020

III. Provider practice location address

315 TURWILL LN
KALAMAZOO MI
49006-4231
US

IV. Provider business mailing address

601 JOHN STREET BOX 42
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 855-618-2676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101025620
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101025620
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: