Basic Information
| Provider Information | |||||||||
| NPI: | 1124464268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIRGIN | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 OSBORN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497831822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062530113 | ||||||||
| FaxNumber: | 5865826631 | ||||||||
| Practice Location | |||||||||
| Address1: | 11855 E 12 MILE RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865866630 | ||||||||
| FaxNumber: | 5865826631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101020536 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 5101020536 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.