Provider Demographics
NPI:1396857892
Name:KELLY, BRIAN G (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25959 KELLY ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066
Mailing Address - Country:US
Mailing Address - Phone:586-773-9510
Mailing Address - Fax:586-773-6888
Practice Address - Street 1:25959 KELLY ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:586-773-9510
Practice Address - Fax:586-773-6888
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301044066207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2884854Medicaid
E25560Medicare UPIN
MI2884854Medicaid