Healthcare Provider Details

I. General information

NPI: 1891081972
Provider Name (Legal Business Name): MARY BRIDGET AVENDT-REEBER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 ANGLING RD
PORTAGE MI
49024-7422
US

IV. Provider business mailing address

1717 SHAFFER ST STE 2
KALAMAZOO MI
49048-1623
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-0944
  • Fax:
Mailing address:
  • Phone: 269-552-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number4301098972
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301098972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: