Healthcare Provider Details

I. General information

NPI: 1023246915
Provider Name (Legal Business Name): KELLY ANN MING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 4TH ST NW
WATERTOWN SD
57201-1558
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-8471
  • Fax: 605-886-9317
Mailing address:
  • Phone: 605-886-8471
  • Fax: 605-886-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301095068
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301095068
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9376
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: