Provider Demographics
NPI:1801896444
Name:KELLY, JOHN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4266 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-4028
Mailing Address - Country:US
Mailing Address - Phone:989-792-6702
Mailing Address - Fax:989-792-1128
Practice Address - Street 1:4266 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-4028
Practice Address - Country:US
Practice Address - Phone:989-792-6702
Practice Address - Fax:989-792-1128
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK004908111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1535385Medicaid
MI350005936OtherRAILROAD MEDICARE
MI0993966OtherHEALTH PLUS
MI950G350220OtherBCBS PIN
MI0G35022OtherBCN
MI0993966OtherHEALTH PLUS
MI0G35022OtherBCN
MI0N24830Medicare ID - Type Unspecified