Provider Demographics
NPI:1629129200
Name:KELLAWAY, JAY EMERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:EMERSON
Last Name:KELLAWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10229 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9554
Mailing Address - Country:US
Mailing Address - Phone:616-842-6757
Mailing Address - Fax:616-842-7256
Practice Address - Street 1:10229 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-9554
Practice Address - Country:US
Practice Address - Phone:616-842-6757
Practice Address - Fax:616-842-7256
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI16862902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology