Provider Demographics
NPI:1669799318
Name:KELLY FAMILY MEDICAL CENTER P.C.
Entity type:Organization
Organization Name:KELLY FAMILY MEDICAL CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALPHONSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EKOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-585-9119
Mailing Address - Street 1:21331 KELLY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3265
Mailing Address - Country:US
Mailing Address - Phone:586-585-9119
Mailing Address - Fax:586-585-9947
Practice Address - Street 1:21331 KELLY RD STE 120
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3265
Practice Address - Country:US
Practice Address - Phone:586-585-9119
Practice Address - Fax:586-585-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080987261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care