Basic Information
| Provider Information | |||||||||
| NPI: | 1841348240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 N 1700 W | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017762180 | ||||||||
| FaxNumber: | 8017762534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012955581 | ||||||||
| FaxNumber: | 8012959253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | 182660-1205 | UT | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 110583300 | 05 | WY | MEDICAID | 003084400 | 05 | ID | MEDICAID |