Healthcare Provider Details

I. General information

NPI: 1396703450
Provider Name (Legal Business Name): KEVIN J KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC ALLERGY/IMMUNOLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC ALLERGY/IMMUNOLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-607-5280
  • Fax: 414-266-6849
Mailing address:
  • Phone: 414-607-5280
  • Fax: 414-266-6849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number22420
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005026718
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: