Basic Information
| Provider Information | |||||||||
| NPI: | 1508803149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
| FaxNumber: | 9895836915 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 CONCENTRIC BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486049312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
| FaxNumber: | 9895836915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 3788 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301022734 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD7303 | 05 | AK | MEDICAID | 381870664 | 01 | MI | TAX ID | OTHER | LK022734 | 01 | MI | LICENSE | OTHER |