Provider Demographics
NPI:1467434357
Name:KELLY, SCOTT PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1109
Mailing Address - Country:US
Mailing Address - Phone:480-221-7599
Mailing Address - Fax:
Practice Address - Street 1:OAKLAWN HOSPITAL
Practice Address - Street 2:200 N. MADISON ST.
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-781-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ752726Medicaid
3981220OtherEVERCARE GRP NBR
AZAW1436OtherHEALTHNET GRP NBR
AZAZ0728670OtherBLUECROSS BLUESHIELD GRP
G81123Medicare UPIN
AZAZ0728670OtherBLUECROSS BLUESHIELD GRP