Provider Demographics
NPI:1053365064
Name:KEMP, MARK WELLS (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WELLS
Last Name:KEMP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN STREET
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 S BAILEY AVE STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-639-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4878533Medicaid
MI3409754Medicaid
MI4183150Medicaid
MI3381662Medicaid
MI4877859Medicaid
MI3494728Medicaid
MI4183150Medicaid
MIP32930018Medicare ID - Type Unspecified
MI3381662Medicaid
MIE78154Medicare UPIN