Provider Demographics
NPI:1598738197
Name:KELLY, MICHAEL W (MD)
Entity Type:Individual
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First Name:MICHAEL
Middle Name:W
Last Name:KELLY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:952-595-6455
Practice Address - Street 1:5100 GAMBLE DR SUITE 100 - MAIL STOP 31200A
Practice Address - Street 2:HEALTHPARTNERS WEST CLINIC
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1582
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:952-595-6455
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-12-12
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Provider Licenses
StateLicense IDTaxonomies
MN26970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400582100Medicaid
MN400582100Medicaid
MN080006755Medicare ID - Type Unspecified