Healthcare Provider Details

I. General information

NPI: 1518354745
Provider Name (Legal Business Name): KELLY M HEFFERON DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 SHENANDOAH CT
W BLOOMFIELD MI
48323-2343
US

IV. Provider business mailing address

5114 SHENANDOAH CT
W BLOOMFIELD MI
48323-2343
US

V. Phone/Fax

Practice location:
  • Phone: 248-230-1780
  • Fax:
Mailing address:
  • Phone: 248-230-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY M HEFFERON
Title or Position: DIRECTOR
Credential: D.O.
Phone: 248-230-1780