Basic Information
| Provider Information | |||||||||
| NPI: | 1700883154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E MOREHEAD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282022742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043347800 | ||||||||
| FaxNumber: | 7044147512 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 E MOREHEAD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282022742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043347800 | ||||||||
| FaxNumber: | 7044147512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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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 | 2085R0202X | 20717 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | C38560 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 20717 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | C38560 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 31847 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 31847 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | NC 300096436 | 01 | NC | RR MEDICARE NC | OTHER | SC 300109599 | 01 | SC | RR MEDICARE SC | OTHER | N31847 | 05 | SC | MEDICAID | 8948125 | 05 | NC | MEDICAID |