1790765139 NPI number — MS. KYOUNG KELLY LEE NP

Table of content: MS. KYOUNG KELLY LEE NP (NPI 1790765139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790765139 NPI number — MS. KYOUNG KELLY LEE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
KYOUNG
Provider Middle Name:
KELLY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
KYOUNG-EUN
Provider Other Middle Name:
KELLY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790765139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 42
Provider Second Line Business Mailing Address:
601 JOHN STREET
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-341-7806
Provider Business Mailing Address Fax Number:
269-341-8743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 WEST CENTRE AVE
Provider Second Line Business Practice Location Address:
BRONSON OB/GYN ASSOCIATES
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-327-2211
Provider Business Practice Location Address Fax Number:
269-327-0273
Provider Enumeration Date:
01/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LX0001X , with the licence number:  4704247830 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4770217 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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