Provider Demographics
NPI:1871671115
Name:KELLY, MICHAEL EDWARD (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 HAMBURG TPKE STE C
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-4093
Mailing Address - Country:US
Mailing Address - Phone:973-277-0868
Mailing Address - Fax:
Practice Address - Street 1:1599 HAMBURG TPKE STE C
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-4093
Practice Address - Country:US
Practice Address - Phone:973-277-0868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00542700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor