Provider Demographics
NPI:1801044714
Name:KELLY, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:504-319-6598
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:504-319-6598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA639092085R0202X
SC35228208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN