Provider Demographics
NPI:1649237991
Name:KELLEY, MICHAEL C (CRNA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12749
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41012-0749
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY028218367500000X
OH136201163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00261495OtherRAILROAD MEDICARE PALMETT
9318802OtherPHCS
IN200304960Medicaid
OH0798892Medicaid
OH000000373372OtherANTHEM
000000555281OtherANTHEM
KY74282187Medicaid
P00463796Medicare PIN
000000555281OtherANTHEM
OH8234343Medicare ID - Type Unspecified
0918145Medicare PIN