Provider Demographics
NPI:1578565560
Name:KELLY, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
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 1:606 24TH AVE S
Mailing Address - Street 2:700
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1455
Mailing Address - Country:US
Mailing Address - Phone:612-672-2450
Mailing Address - Fax:
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:700
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-672-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 26969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
08625KEOtherBLUE CROSS
MN505272600Medicaid
0104320OtherMEDICA
080026085OtherRAILROAD MEDICARE
FP 3205OtherAMERICAS PPO
107074C620OtherUCARE FOR SENIOR
107074OtherUCARE MEDICAL ASSIST
FP1420457002OtherPREFERRED ONE
080026085OtherRAILROAD MEDICARE
FP 3205OtherAMERICAS PPO