Provider Demographics
NPI:1689868697
Name:KEVIN J. KELLY MD, PC
Entity Type:Organization
Organization Name:KEVIN J. KELLY MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-324-9162
Mailing Address - Street 1:8145 VALLEYWOOD LN STE B
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5296
Mailing Address - Country:US
Mailing Address - Phone:269-324-9162
Mailing Address - Fax:269-375-6079
Practice Address - Street 1:8145 VALLEYWOOD LN STE B
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5296
Practice Address - Country:US
Practice Address - Phone:269-324-9162
Practice Address - Fax:269-375-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-02
Last Update Date:2007-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI039833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0390022OtherBCBSM
MI4282408Medicaid
MI0N23170Medicare PIN