Provider Demographics
NPI:1306822812
Name:KELLEY, MICHAEL TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8E BROAD ST 501
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3435
Mailing Address - Country:US
Mailing Address - Phone:614-486-7774
Mailing Address - Fax:
Practice Address - Street 1:1166 DUBLIN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1030
Practice Address - Country:US
Practice Address - Phone:614-544-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048006K2083X0100X
KY390722083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0672811Medicaid
OH0672811Medicaid
OHKE7004622Medicare ID - Type Unspecified