Basic Information
| Provider Information | |||||||||
| NPI: | 1942521323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSHING | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | COLLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 CHALLIS RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102634000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2010 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2013017117 | MO | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | 4301114466 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 4301114466 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.