Basic Information
| Provider Information | |||||||||
| NPI: | 1578585501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST. | ||||||||
| Address2: | #210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883663 | ||||||||
| FaxNumber: | 5039884098 | ||||||||
| Practice Location | |||||||||
| Address1: | 12710 SE DIVISION STREET | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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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 | 207Q00000X | 47017 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BK7429930 | 01 | MN | DEA # | OTHER |