Provider Demographics
NPI:1023088218
Name:KELLETT, MIRLE A (MD)
Entity type:Individual
Prefix:
First Name:MIRLE
Middle Name:A
Last Name:KELLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:96 CAMPUS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7133
Practice Address - Country:US
Practice Address - Phone:207-396-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD12317207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME282560099Medicaid
MEMM082701Medicare PIN
MEMM082704Medicare PIN
MEMM082702Medicare PIN
MESX2319Medicare PIN
MEMM082703Medicare PIN
MEP01008211Medicare PIN
MEP01038410Medicare PIN
ME282560099Medicaid
MEKE MM0827Medicare PIN
ME060070248Medicare PIN