Provider Demographics
NPI:1477530269
Name:KELLY, GRAHAM M (DO)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3496 E LAKE LANSING RD
Mailing Address - Street 2:STE. 160
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2288
Mailing Address - Country:US
Mailing Address - Phone:517-371-5515
Mailing Address - Fax:517-371-5564
Practice Address - Street 1:3496 E LAKE LANSING RD
Practice Address - Street 2:STE. 160
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2288
Practice Address - Country:US
Practice Address - Phone:517-371-5515
Practice Address - Fax:517-371-5564
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGK008737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5330103Medicare ID - Type Unspecified
E31889Medicare UPIN