Healthcare Provider Details

I. General information

NPI: 1487632014
Provider Name (Legal Business Name): KELLY M KRUEGER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39555 W. TEN MILE #302
NOVI MI
48375
US

IV. Provider business mailing address

39555 W. TEN MILE #302
NOVI MI
48375
US

V. Phone/Fax

Practice location:
  • Phone: 248-426-7200
  • Fax: 247-426-7335
Mailing address:
  • Phone: 248-426-7200
  • Fax: 247-426-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101011317
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: