Healthcare Provider Details

I. General information

NPI: 1376732016
Provider Name (Legal Business Name): JUSTIN TYLER SYBESMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 PEACE BLVD
SAINT JOSEPH MI
49085-9146
US

IV. Provider business mailing address

183 PEACE BLVD
SAINT JOSEPH MI
49085-9146
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-3500
  • Fax: 269-429-6429
Mailing address:
  • Phone: 269-428-3500
  • Fax: 269-429-6429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301083923
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: