Healthcare Provider Details

I. General information

NPI: 1952889073
Provider Name (Legal Business Name): KELLY MCGREGORY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 BASS LAKE RD STE 102
CRYSTAL MN
55429
US

IV. Provider business mailing address

6000 BASS LAKE RD STE 102
CRYSTAL MN
55429-2768
US

V. Phone/Fax

Practice location:
  • Phone: 815-975-7555
  • Fax:
Mailing address:
  • Phone: 763-334-5151
  • Fax: 612-324-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY MCGREGORY
Title or Position: PEDIATRICIAN
Credential: DO
Phone: 763-334-5151