Provider Demographics
NPI:1265623748
Name:JOHN KELLY, MD, PLLC
Entity type:Organization
Organization Name:JOHN KELLY, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-423-9300
Mailing Address - Street 1:115 S EVANS ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1949
Mailing Address - Country:US
Mailing Address - Phone:517-423-9300
Mailing Address - Fax:517-423-9400
Practice Address - Street 1:115 S EVANS ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1949
Practice Address - Country:US
Practice Address - Phone:517-423-9300
Practice Address - Fax:517-423-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK057968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4970844Medicaid
MI0P48280Medicare PIN
MIF87859Medicare UPIN