Provider Demographics
NPI:1114187705
Name:KELLY, MOLLY MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:MAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MOLLY
Other - Middle Name:MAE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2202 HARLEM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:2202 HARLEM RD STE 200
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-636-6125
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130382207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130382Medicaid