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General NPI Number Information
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NPI Number | 1275580672
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Entity Type | Individual
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Provider Name | TERESA GROSS KELLY M.D
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Gender | Female
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Dates
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Enumeration Date | 05/30/2006
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 3264 N EVERGREEN DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9746
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Country | US
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Telephone | 616-363-7272
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Fax | 616-361-5828
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Provider Business Mailing Address
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Address Line | 3264 N EVERGREEN DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9746
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Country | US
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Telephone | 616-363-7272
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Fax | 616-361-5828
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 4301052060
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2085P0229X
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Taxonomy Name | Pediatric Radiology Physician
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License Number | 52993
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 2085P0229X
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Taxonomy Name | Pediatric Radiology Physician
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License Number | ME70684
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License Number State | FL
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