Provider Demographics
NPI:1689608093
Name:CAMPBELL, KELLY M (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:5777 W MAPLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2267
Mailing Address - Country:US
Mailing Address - Phone:248-932-9223
Mailing Address - Fax:248-932-8641
Practice Address - Street 1:5777 W MAPLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2267
Practice Address - Country:US
Practice Address - Phone:248-932-9223
Practice Address - Fax:248-932-8641
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIKC061242207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKC061242OtherSTATE LICENSE
MI0M92560003Medicare ID - Type Unspecified
MIKC061242OtherSTATE LICENSE