Healthcare Provider Details

I. General information

NPI: 1700884814
Provider Name (Legal Business Name): MAUREEN A KELLY MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43205 WOODWARD AVE
BLOOMFIELD HILLS MI
48302-5006
US

IV. Provider business mailing address

PO BOX 44047
DETROIT MI
48244-0047
US

V. Phone/Fax

Practice location:
  • Phone: 248-451-0600
  • Fax: 248-451-0700
Mailing address:
  • Phone: 248-451-0600
  • Fax: 248-451-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301056543
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier104183802
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 2
Identifier1015775
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerHEALTH ADVANTAGE
# 3
Identifier350F302120
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBC GROUP
# 4
Identifier1700884814
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 5
Identifier350F302120
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBCN GROUP

VIII. Authorized Official

Name: DR. MAUREEN KELLY
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 248-451-0600