Provider Demographics
NPI:1528593894
Name:MCPHILLIPS, KELLY M (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MCPHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:MANGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29804 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4611
Practice Address - Country:US
Practice Address - Phone:440-833-2095
Practice Address - Fax:440-833-2096
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.029951207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230630Medicaid