Provider Demographics
NPI:1942521323
Name:CUSHING-DAMM, KELLY COLLEEN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:COLLEEN
Last Name:CUSHING-DAMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:COLLEEN
Other - Last Name:CUSHING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:7500 CHALLIS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9416
Practice Address - Country:US
Practice Address - Phone:810-263-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-19
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017117208D00000X
MI4301114466207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine