Provider Demographics
NPI:1376732016
Name:SYBESMA, JUSTIN TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TYLER
Last Name:SYBESMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:183 PEACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9146
Mailing Address - Country:US
Mailing Address - Phone:269-428-3500
Mailing Address - Fax:269-429-6429
Practice Address - Street 1:183 PEACE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9146
Practice Address - Country:US
Practice Address - Phone:269-428-3500
Practice Address - Fax:269-429-6429
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301083923207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376732016Medicaid
MI2003901922OtherBLUE CROSS BLUE SHIELD
MI0C97618276Medicare PIN
MI1376732016Medicaid