Provider Demographics
NPI:1326129503
Name:MCCLEAN, KELLY L (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MCCLEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:7300 DEXTER-ANN ARBOR RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-8598
Practice Address - Country:US
Practice Address - Phone:734-426-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073167207N00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3502982Medicaid
MI3502982Medicaid
MI0H16012035Medicare ID - Type Unspecified