Provider Demographics
NPI:1265583884
Name:KELLY, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-736-1939
Mailing Address - Fax:973-736-1937
Practice Address - Street 1:776 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-736-1939
Practice Address - Fax:973-736-1937
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07620900207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ203812206OtherTAX ID FOR SECOND OFFICE NJ SPORTS MEDICINE CENTER
NJ7331613OtherAETNA PROVIDER NUMBER
NJ1619025038OtherMEDICARE PIN SECOND OFFICE GROUP NUMBER
NJP3389558OtherOXFORD PROVIDER NUMBER
NJP3389558OtherOXFORD PROVIDER NUMBER
NJ084762Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NJP3389558OtherOXFORD PROVIDER NUMBER