Healthcare Provider Details

I. General information

NPI: 1912981010
Provider Name (Legal Business Name): MICHAEL KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 HYLAND ST
FERNDALE MI
48220-3803
US

IV. Provider business mailing address

1933 HYLAND ST
FERNDALE MI
48220-3803
US

V. Phone/Fax

Practice location:
  • Phone: 248-933-0558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301065795
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number86418
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: