Basic Information
| Provider Information | |||||||||
| NPI: | 1396766937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 WEST THIRD STREET | ||||||||
| Address2: | GENESIS HEALTH GROUP | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528020000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634210500 | ||||||||
| FaxNumber: | 5633261901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 W 3RD ST | ||||||||
| Address2: | GENESIS HEALTH GROUP | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528021812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634210500 | ||||||||
| FaxNumber: | 5633261901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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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 | 036-079295 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 24314 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2019320 | 01 | PHYSICIANS PLUS | OTHER | 390808509DX | 01 | UNITY | OTHER | 14313 | 01 | DEAN HEALTH PLAN | OTHER | 390808509 | 01 | CIGNA | OTHER |