Provider Demographics
NPI:1609071836
Name:KELLY, PAUL D
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 N. MITCHELL
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601
Mailing Address - Country:US
Mailing Address - Phone:231-779-2100
Mailing Address - Fax:231-779-3050
Practice Address - Street 1:932 N MITCHELL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1285
Practice Address - Country:US
Practice Address - Phone:231-779-2100
Practice Address - Fax:231-779-3050
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH35007Medicare ID - Type Unspecified