Provider Demographics
NPI:1164474631
Name:KELLY, MICHAEL EARL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EARL
Last Name:KELLY
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 1:420 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9237
Mailing Address - Country:US
Mailing Address - Phone:269-463-3600
Mailing Address - Fax:269-463-5356
Practice Address - Street 1:420 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9237
Practice Address - Country:US
Practice Address - Phone:269-463-3600
Practice Address - Fax:269-463-5356
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009399207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI93384289OtherRR MEDICARE
MI11-5193581 HARTFORDMedicaid
MI3025952-11OtherMEDICAID - THREE RIVERS
MI4155933-11OtherMEDICAID - PIPP
MIMK009399OtherBCBS IND LIC #
MI11-4924242 COLOMAMedicaid
MI5391075OtherBCBS IND PIN #
MIG56008112OtherMEDICARE - THREE RIVERS
MI93384289OtherRR MEDICARE - PIPP
MI93384289OtherRR MEDICARE - PIPP
MI4155933-11OtherMEDICAID - PIPP
MI11-5193581 HARTFORDMedicaid
MI0M90900006Medicare PIN