Provider Demographics
NPI:1740543222
Name:DENNIS G KELLY DO PC
Entity type:Organization
Organization Name:DENNIS G KELLY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-398-4614
Mailing Address - Street 1:1431 E 12 MILE RD
Mailing Address - Street 2:BLDG C
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2653
Mailing Address - Country:US
Mailing Address - Phone:248-398-4614
Mailing Address - Fax:248-398-4345
Practice Address - Street 1:1431 E 12 MILE RD
Practice Address - Street 2:BLDG C
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2653
Practice Address - Country:US
Practice Address - Phone:248-398-4614
Practice Address - Fax:248-398-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDK008799261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2727880 TYPE 11Medicaid
MIE66886Medicare UPIN