Provider Demographics
NPI:1366689275
Name:THOMAS A. KELLY D.O. P.C.
Entity Type:Organization
Organization Name:THOMAS A. KELLY D.O. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-663-2705
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-0417
Mailing Address - Country:US
Mailing Address - Phone:517-663-2705
Mailing Address - Fax:517-663-9470
Practice Address - Street 1:101 E SPICERVILLE HWY
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1919
Practice Address - Country:US
Practice Address - Phone:517-663-2705
Practice Address - Fax:517-663-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008344208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0152330085OtherBLUE CROSS BLUE SHIELD PPO TRUST
MI10046150001OtherTHE WELLNESS PLAN MEDICAID
0279722OtherCIGNA HEALTHCARE
0100444OtherPHYSICIAN HEALTH PLAN
MI0152330085OtherBLUE CHOICE
MI3319192Medicaid
MI0152330085OtherBLUE CROSS BLUE SHIELD MEDICAL PIN
MI10046150001OtherTHE WELLNESS PLAN
MI202869OtherMCLAREN
MI0152330085OtherBLUE PREFFERED PLUS
MIP93421OtherBLUE CARE NETWORK
MI200000002219OtherPHYSICIAN HEALTH PLAN FAMILY CARE
M034742OtherCHAMPUS
M034742OtherCHAMPUS
F03642Medicare UPIN