Healthcare Provider Details

I. General information

NPI: 1316048408
Provider Name (Legal Business Name): MICHAEL JOHN KELLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FULTON ST HEME/ONC (111G)
DURHAM NC
27705-3875
US

IV. Provider business mailing address

508 FULTON ST HEME/ONC (111G)
DURHAM NC
27705-3875
US

V. Phone/Fax

Practice location:
  • Phone: 919-286-0411
  • Fax: 919-286-6896
Mailing address:
  • Phone: 919-286-0411
  • Fax: 919-286-6896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number32252
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: