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NPI Code Detail

MEDICARE: DR. KELLY CARMELA KETCHUM MD

MEDICARE: DR. KELLY CARMELA KETCHUM 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
12084P0800XPsychiatry Physician4301112519MI
22084P0800XPsychiatry Physician4351036514MI

General Provider Information

NPI Number : 1942739842
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KELLY CARMELA KETCHUM MD
Provider Business Mailing Address
First Line : 2790 HEALTH PKWY
Second Line :
City : MT PLEASANT
State : MI
Zip : 48858-6934
Country : US
Telephone Number : 989-953-5320
Fax Number : 899-953-5329
Provider Business Practice Location Address
First Line : 2790 HEALTH PKWY
Second Line :
City : MT PLEASANT
State : MI
Zip : 48858-6934
Country : US
Telephone Number : 989-953-5320
Fax Number : 899-953-5329
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/06/2017
Last Update Date : 04/09/2021

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