Provider Demographics
NPI:1831190313
Name:KELLIS, MICHAEL J (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:KELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:440-285-4999
Mailing Address - Fax:440-285-5870
Practice Address - Street 1:150 SEVENTH AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-2909
Practice Address - Country:US
Practice Address - Phone:440-285-4999
Practice Address - Fax:402-855-8704
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-11-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH34004183207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH139662OtherANTHEM
OH250006704OtherRR MEDICARE
OH0658051Medicaid
OH4073792OtherAETNA
OH0658051Medicaid