Provider Demographics
NPI:1891956918
Name:GEORGE J KELEN MD PLLC
Entity Type:Organization
Organization Name:GEORGE J KELEN MD PLLC
Other - Org Name:LAKESHORE CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:231-845-7677
Mailing Address - Street 1:913 E LUDINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2437
Mailing Address - Country:US
Mailing Address - Phone:231-845-7677
Mailing Address - Fax:231-843-0773
Practice Address - Street 1:913 E LUDINGTON AVE
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2437
Practice Address - Country:US
Practice Address - Phone:231-845-7677
Practice Address - Fax:231-843-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079843261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4579580Medicaid
MIDA9989OtherRAILROAD MEDICARE
MIG00681Medicare UPIN
MIDA9989OtherRAILROAD MEDICARE