Healthcare Provider Details

I. General information

NPI: 1588792097
Provider Name (Legal Business Name): KELLY MICHELE MALLOY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR 1ST FLOOR TAUBMAN CTR RECP A
ANN ARBOR MI
48109-5312
US

IV. Provider business mailing address

3621 S STATE STREET 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-8051
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD426319
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301089143
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number4301089143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: