Provider Demographics
NPI:1083685523
Name:KELLY, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1510 N 28TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-5311
Mailing Address - Country:US
Mailing Address - Phone:804-545-2304
Mailing Address - Fax:804-545-2306
Practice Address - Street 1:1510 N 28TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5311
Practice Address - Country:US
Practice Address - Phone:804-545-2304
Practice Address - Fax:804-545-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101246237207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1649302Medicaid
VAC06695OtherGROUP PTAN
NJ453387Medicare PIN
VAC06695OtherGROUP PTAN