Provider Demographics
NPI:1922115070
Name:KELLY, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 52948
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2948
Mailing Address - Country:US
Mailing Address - Phone:865-306-5675
Mailing Address - Fax:865-584-7712
Practice Address - Street 1:9430 PARK WEST BLVD STE 310
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4203
Practice Address - Country:US
Practice Address - Phone:865-690-5263
Practice Address - Fax:865-588-3740
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34159208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3896741Medicaid
3896741Medicare PIN
TN3896741Medicaid