Healthcare Provider Details

I. General information

NPI: 1144551805
Provider Name (Legal Business Name): KELLY M KRUEGER DO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39555 W 10 MILE RD SUITE 305
NOVI MI
48375-2950
US

IV. Provider business mailing address

39555 W 10 MILE RD SUITE 305
NOVI MI
48375-2950
US

V. Phone/Fax

Practice location:
  • Phone: 248-426-7200
  • Fax: 586-426-7335
Mailing address:
  • Phone: 248-426-7200
  • Fax: 586-426-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51010011317
License Number StateMI

VIII. Authorized Official

Name: DR. KELLY M KRUEGER
Title or Position: OWNER
Credential: DO
Phone: 248-426-7200