Healthcare Provider Details

I. General information

NPI: 1295726628
Provider Name (Legal Business Name): JOHN JOSEPH KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/18/2011
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 Number4301057968
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: