Healthcare Provider Details

I. General information

NPI: 1831179407
Provider Name (Legal Business Name): KELLY D YBEMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY A DERMODY MD

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 GULL RD STE 100
KALAMAZOO MI
49048-1645
US

IV. Provider business mailing address

1541 GULL RD STE 100
KALAMAZOO MI
49048-1645
US

V. Phone/Fax

Practice location:
  • Phone: 269-381-7380
  • Fax:
Mailing address:
  • Phone: 269-381-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301085566
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: