Healthcare Provider Details

I. General information

NPI: 1043284698
Provider Name (Legal Business Name): MICHAEL D KELLEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-6665
  • Fax: 937-395-6668
Mailing address:
  • Phone: 937-395-6665
  • Fax: 937-395-6668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50003217
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50003217
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: