Provider Demographics
NPI:1831179407
Name:YBEMA, KELLY D (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:YBEMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:DERMODY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1541 GULL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1645
Mailing Address - Country:US
Mailing Address - Phone:269-381-7380
Mailing Address - Fax:
Practice Address - Street 1:1541 GULL RD STE 100
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1645
Practice Address - Country:US
Practice Address - Phone:269-381-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010855662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4771457Medicaid
MICA2184OtherRAILROAD MEDICARE
I41177Medicare UPIN
MIC97618097Medicare PIN