Provider Demographics
NPI:1578518817
Name:KELLY, RALPH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2205 JOLLY RD
Practice Address - Street 2:STE B
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3983
Practice Address - Country:US
Practice Address - Phone:517-347-4085
Practice Address - Fax:517-347-4170
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037517207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1103303981OtherBCBS/BCN
MI76-00059OtherPHP
MI1015806OtherMCLAREN HEALTH PLAN
MI04-70140OtherPHP FAMILYCARE
MI200000002216OtherPHYSICIANS HEALTH PLAN
MI4617125Medicaid
MI1015806OtherMCLAREN HEALTH ADVANTAGE
MI4848060Medicaid
MI04-00140OtherPHP
MI5685669OtherAETNA
MI76-70048OtherPHP FAMILYCARE
MIP00142308OtherRAILROAD MEDICARE
MI04-00140OtherPHP
MIA73969Medicare UPIN