Provider Demographics
NPI:1700884814
Name:MAUREEN A KELLY MD PLLC
Entity Type:Organization
Organization Name:MAUREEN A KELLY MD PLLC
Other - Org Name:BLOOMFIELD PEDIATRIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-451-0600
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-451-0600
Mailing Address - Fax:248-451-0700
Practice Address - Street 1:43205 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5006
Practice Address - Country:US
Practice Address - Phone:248-451-0600
Practice Address - Fax:248-451-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010565432080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104183802Medicaid
MI1015775OtherHEALTH ADVANTAGE
MI350F302120OtherBC GROUP
MI1700884814Medicaid
MI350F302120OtherBCN GROUP