Provider Demographics
NPI:1548221146
Name:KELLY, JOHN F (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1655 BEAM AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1163
Mailing Address - Country:US
Mailing Address - Phone:651-232-7800
Mailing Address - Fax:651-232-7826
Practice Address - Street 1:1655 BEAM AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1163
Practice Address - Country:US
Practice Address - Phone:651-232-7800
Practice Address - Fax:651-232-7826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN37405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG01609Medicare UPIN