Provider Demographics
NPI:1629033444
Name:KELLY, THOMAS ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E SPICERVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1919
Mailing Address - Country:US
Mailing Address - Phone:517-663-2705
Mailing Address - Fax:
Practice Address - Street 1:101 E SPICERVILLE HWY
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1919
Practice Address - Country:US
Practice Address - Phone:517-663-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008344207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0152330085OtherBLUECROSS BLUE SHIELD PIN
MI0170444OtherPHP FAMIL CARE
MI0100444OtherPHP
MIC6121OtherMCARE
MIM034742OtherCHAMPUS
MI3319192Medicaid
MIC6121OtherMCARE
MI3319192Medicaid