Provider Demographics
NPI:1952889073
Name:KELLY MCGREGORY PEDIATRICS LLC
Entity Type:Organization
Organization Name:KELLY MCGREGORY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:763-334-5151
Mailing Address - Street 1:6000 BASS LAKE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2768
Mailing Address - Country:US
Mailing Address - Phone:763-334-5151
Mailing Address - Fax:612-324-7445
Practice Address - Street 1:6000 BASS LAKE RD STE 102
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:815-975-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty