Basic Information
Provider Information | |||||||||
NPI: | 1104057843 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DOWDEN | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1000 REMINGTON BLVD | ||||||||
Address2: | SUITE 200 ATTN: AIM | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604405114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303127755 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 REMINGTON BLVD | ||||||||
Address2: | SUITE 200 ATTN: AIM | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604405114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303127755 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2009 | ||||||||
LastUpdateDate: | 03/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036.128764 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 036-128764 | IL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.