Provider Demographics
NPI:1558866525
Name:KELLY, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:523 E 72ND ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4099
Mailing Address - Country:US
Mailing Address - Phone:212-224-7994
Mailing Address - Fax:917-260-4980
Practice Address - Street 1:523 E 72ND ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4099
Practice Address - Country:US
Practice Address - Phone:212-224-7994
Practice Address - Fax:917-260-4980
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY322187207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery