Provider Demographics
NPI:1538307699
Name:GUMBRECHT, KELLY MARIE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:GUMBRECHT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W UNIVERSITY DR
Mailing Address - Street 2:STE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1871
Mailing Address - Country:US
Mailing Address - Phone:248-656-2022
Mailing Address - Fax:
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:STE 100
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1871
Practice Address - Country:US
Practice Address - Phone:248-656-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086582207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE07871007Medicare UPIN