Provider Demographics
NPI:1467477091
Name:KELLY, PATRICIA E (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:KELLY
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 1:2340 E STADIUM BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4823
Mailing Address - Country:US
Mailing Address - Phone:734-995-5982
Mailing Address - Fax:734-995-9659
Practice Address - Street 1:2340 E STADIUM BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4823
Practice Address - Country:US
Practice Address - Phone:734-995-5982
Practice Address - Fax:734-995-9659
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0811156Medicare ID - Type Unspecified
MID92491Medicare UPIN