Provider Demographics
NPI:1740374230
Name:KELLY MEDICAL SERVICES, S.C.
Entity type:Organization
Organization Name:KELLY MEDICAL SERVICES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-567-6927
Mailing Address - Street 1:820 E. SUMMIT AVE.
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066
Mailing Address - Country:US
Mailing Address - Phone:262-567-6927
Mailing Address - Fax:262-567-8003
Practice Address - Street 1:820 E. SUMMIT AVE.
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-567-6927
Practice Address - Fax:262-567-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24545261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30453000Medicaid
WI30453000Medicaid
WI30453000Medicaid
WI=========OtherUNITED HEALTH CARE