Provider Demographics
NPI:1255505111
Name:CHRISTOPHER B KELLY MD PC
Entity Type:Organization
Organization Name:CHRISTOPHER B KELLY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-243-6640
Mailing Address - Street 1:1066 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3113
Mailing Address - Country:US
Mailing Address - Phone:734-243-6640
Mailing Address - Fax:734-243-6643
Practice Address - Street 1:1066 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3113
Practice Address - Country:US
Practice Address - Phone:734-243-6640
Practice Address - Fax:734-243-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK055724208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2849194Medicaid
MIA03589Medicare UPIN
MI0N28960Medicare PIN