Healthcare Provider Details

I. General information

NPI: 1912437187
Provider Name (Legal Business Name): DANIEL KELLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR STE 924
CHICAGO IL
60611-8701
US

IV. Provider business mailing address

680 N LAKE SHORE DR STE 924
CHICAGO IL
60611-8701
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax:
Mailing address:
  • Phone: 847-866-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML60770434
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberML60770434
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036152896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: