Provider Demographics
NPI:1952512311
Name:DAVID P. KELSEY, M.D. KELSEY MEDICAL CENTER
Entity Type:Organization
Organization Name:DAVID P. KELSEY, M.D. KELSEY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-469-8484
Mailing Address - Street 1:5 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117-1734
Mailing Address - Country:US
Mailing Address - Phone:269-469-8484
Mailing Address - Fax:
Practice Address - Street 1:5 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1734
Practice Address - Country:US
Practice Address - Phone:269-469-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI204F00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5177828Medicaid
MI5177828Medicaid
MI0P43650Medicare PIN
MI5177828Medicaid