Provider Demographics
NPI:1487632014
Name:KRUEGER, KELLY M (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39555 W. TEN MILE
Mailing Address - Street 2:#302
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375
Mailing Address - Country:US
Mailing Address - Phone:248-426-7200
Mailing Address - Fax:247-426-7335
Practice Address - Street 1:39555 W. TEN MILE
Practice Address - Street 2:#302
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:248-426-7200
Practice Address - Fax:247-426-7335
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101011317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine