Provider Demographics
NPI:1093806309
Name:KELLY, MICHAEL G (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 TARBORO ST W
Mailing Address - Street 2:PO BOX 7463
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4758
Mailing Address - Country:US
Mailing Address - Phone:252-291-7088
Mailing Address - Fax:252-293-1100
Practice Address - Street 1:1004 TARBORO ST W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4758
Practice Address - Country:US
Practice Address - Phone:252-291-7088
Practice Address - Fax:252-293-1100
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0845COtherBCBS
NC890845CMedicaid
NC2454051AMedicare PIN
NCU78061Medicare UPIN