Provider Demographics
NPI:1336104488
Name:KELLY, TARA L (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:N
Other - Last Name:LASOVAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-327-0872
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:1513 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1434
Practice Address - Country:US
Practice Address - Phone:734-475-9175
Practice Address - Fax:734-475-0120
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics