Provider Demographics
NPI:1508803149
Name:KELLY, LARRY S (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:KELLY
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 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-583-6800
Mailing Address - Fax:989-583-6915
Practice Address - Street 1:1575 CONCENTRIC BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9312
Practice Address - Country:US
Practice Address - Phone:989-583-6800
Practice Address - Fax:989-583-6915
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3788207Q00000X
MI4301022734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD7303Medicaid
MI381870664OtherTAX ID
MILK022734OtherLICENSE
MILK022734OtherLICENSE