Healthcare Provider Details

I. General information

NPI: 1265623748
Provider Name (Legal Business Name): JOHN KELLY, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S EVANS ST
TECUMSEH MI
49286-1949
US

IV. Provider business mailing address

115 S EVANS ST
TECUMSEH MI
49286-1949
US

V. Phone/Fax

Practice location:
  • Phone: 517-423-9300
  • Fax: 517-423-9400
Mailing address:
  • Phone: 517-423-9300
  • Fax: 517-423-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJK057968
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN J. KELLY
Title or Position: PHYSICIAN
Credential: MD
Phone: 517-423-9300