Provider Demographics
NPI:1346516689
Name:FITZGERALD, KELLY M (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2215 SANDERS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6194
Mailing Address - Country:US
Mailing Address - Phone:224-330-6303
Mailing Address - Fax:312-943-6924
Practice Address - Street 1:2215 SANDERS RD STE 105
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-6194
Practice Address - Country:US
Practice Address - Phone:224-330-6303
Practice Address - Fax:312-943-6924
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.137701208000000X
CAA148400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics