Provider Demographics
NPI:1871661645
Name:KELLEY, MICHAEL H (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:KELLEY
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 1:4615 OLEANDER DR
Mailing Address - Street 2:SUITE 201A
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5741
Mailing Address - Country:US
Mailing Address - Phone:843-497-5929
Mailing Address - Fax:843-497-6601
Practice Address - Street 1:3361 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7826
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:843-399-3494
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-003256207Q00000X
SCTL1223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE69615Medicare UPIN