Provider Demographics
NPI:1376703751
Name:MICHAEL J. KELLY MD
Entity Type:Organization
Organization Name:MICHAEL J. KELLY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-435-3551
Mailing Address - Street 1:PO BOX 1748
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06039-1748
Mailing Address - Country:US
Mailing Address - Phone:860-435-3551
Mailing Address - Fax:860-435-3561
Practice Address - Street 1:308 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:CT
Practice Address - Zip Code:06039-1204
Practice Address - Country:US
Practice Address - Phone:860-435-3551
Practice Address - Fax:860-435-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001417270Medicaid
1124102546OtherNPI
1124102546OtherNPI
CT001417270Medicaid