Healthcare Provider Details

I. General information

NPI: 1093823130
Provider Name (Legal Business Name): THOMAS KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NTH MAYFAIR RD 2ND FLOOR
WAUWATOSA WI
53226
US

IV. Provider business mailing address

201 NTH MAYFAIR RD 2ND FLOOR
WAUWATOSA WI
53226
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-8228
  • Fax: 414-256-2483
Mailing address:
  • Phone: 414-771-8228
  • Fax: 414-256-2483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number31137
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: