MEDICARE: KEVIN M KELLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MN 26969	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	080026085	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	08625KE	OTHER	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0104320	OTHER	MEDICA
5	FP 3205	OTHER	AMERICAS PPO
6	107074C620	OTHER	UCARE FOR SENIOR
7	107074	OTHER	UCARE MEDICAL ASSIST
8	FP1420457002	OTHER	PREFERRED ONE

General Provider Information

NPI Number	:	1578565560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN M KELLY MD

Provider Business Mailing Address
First Line	:	606 24TH AVE S
Second Line	:	700
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454-1455
Country	:	US
Telephone Number	:	612-672-2450
Fax Number	:

Provider Business Practice Location Address
First Line	:	606 24TH AVE S
Second Line	:	700
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454-1455
Country	:	US
Telephone Number	:	612-672-2450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	04/05/2012

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Directions to “ KEVIN M KELLY MD” Practice Location

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