Provider Demographics
NPI:1396712055
Name:FITZGIBBONS, KELLY (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FITZGIBBONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33523 8 MILE RD
Mailing Address - Street 2:STE M2
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4119
Mailing Address - Country:US
Mailing Address - Phone:734-432-7591
Mailing Address - Fax:734-853-5698
Practice Address - Street 1:37595 7 MILE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-432-7591
Practice Address - Fax:734-853-5698
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619139Medicaid
N91620034Medicare ID - Type Unspecified
MI4619139Medicaid