Healthcare Provider Details

I. General information

NPI: 1316830466
Provider Name (Legal Business Name): KYLE ANDREW ROOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 E MICHIGAN AVE STE 202B
LANSING MI
48912-2109
US

IV. Provider business mailing address

1322 E MICHIGAN AVE STE 202B
LANSING MI
48912-2109
US

V. Phone/Fax

Practice location:
  • Phone: 586-854-1595
  • Fax:
Mailing address:
  • Phone: 517-364-5710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351054366
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: