Healthcare Provider Details

I. General information

NPI: 1801278783
Provider Name (Legal Business Name): MICHAEL KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 KINSLEY ST STE 201
NASHUA NH
03060
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 603-880-9177
  • Fax: 603-880-9672
Mailing address:
  • Phone: 207-777-8695
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberLL 1332
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0371
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: