Provider Demographics
NPI:1801278783
Name:KELLY, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:166 KINSLEY ST STE 201
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060
Practice Address - Country:US
Practice Address - Phone:603-880-9177
Practice Address - Fax:603-880-9672
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALL 1332213ES0103X
NH0371213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery