Healthcare Provider Details

I. General information

NPI: 1699113738
Provider Name (Legal Business Name): KELLY MARIE WELKER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE BRADY

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125062808
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101022412
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: