Basic Information
| Provider Information | |||||||||
| NPI: | 1265464804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10187 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122015187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077774111 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CAMPUS AVE | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042406040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778974 | ||||||||
| FaxNumber: | 2077778946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/22/2011 | ||||||||
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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 | 2084P0800X | 014859 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 339290099 | 05 | ME | MEDICAID |