Provider Demographics
NPI:1750338745
Name:KELLEY, JOHN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATWELL RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-547-4770
Mailing Address - Fax:607-547-7891
Practice Address - Street 1:2211 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-733-7798
Practice Address - Fax:315-733-7893
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190295-1208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01489990Medicaid
NYF86079Medicare UPIN