Basic Information
| Provider Information | |||||||||
| NPI: | 1164474631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490989237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694633600 | ||||||||
| FaxNumber: | 2694635356 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490989237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694633600 | ||||||||
| FaxNumber: | 2694635356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009399 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 5101009399 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 93384289 | 01 | MI | RR MEDICARE | OTHER | 11-5193581 HARTFORD | 05 | MI | MEDICAID | 3025952-11 | 01 | MI | MEDICAID - THREE RIVERS | OTHER | 4155933-11 | 01 | MI | MEDICAID - PIPP | OTHER | MK009399 | 01 | MI | BCBS IND LIC # | OTHER | 11-4924242 COLOMA | 05 | MI | MEDICAID | 5391075 | 01 | MI | BCBS IND PIN # | OTHER | G56008112 | 01 | MI | MEDICARE - THREE RIVERS | OTHER | 93384289 | 01 | MI | RR MEDICARE - PIPP | OTHER |