Healthcare Provider Details

I. General information

NPI: 1396766937
Provider Name (Legal Business Name): MICHAEL J KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W 3RD ST GENESIS HEALTH GROUP
DAVENPORT IA
52802-1812
US

IV. Provider business mailing address

1820 WEST THIRD STREET GENESIS HEALTH GROUP
DAVENPORT IA
52802-0000
US

V. Phone/Fax

Practice location:
  • Phone: 563-421-0500
  • Fax: 563-326-1901
Mailing address:
  • Phone: 563-421-0500
  • Fax: 563-326-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-079295
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24314
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: