Provider Demographics
NPI:1518354745
Name:KELLY M HEFFERON DO PC
Entity Type:Organization
Organization Name:KELLY M HEFFERON DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HEFFERON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-230-1780
Mailing Address - Street 1:5114 SHENANDOAH CT
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2343
Mailing Address - Country:US
Mailing Address - Phone:248-230-1780
Mailing Address - Fax:
Practice Address - Street 1:5114 SHENANDOAH CT
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2343
Practice Address - Country:US
Practice Address - Phone:248-230-1780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty