Healthcare Provider Details

I. General information

NPI: 1578518817
Provider Name (Legal Business Name): RALPH MICHAEL KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 JOLLY RD STE B
OKEMOS MI
48864-3983
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-4085
  • Fax: 517-347-4170
Mailing address:
  • Phone: 248-824-6600
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301037517
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number4301037517
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: