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General NPI Number Information
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NPI Number | 1376703751
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Entity Type | Organization
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Legal Business Name | MICHAEL J. KELLY MD
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 308 MAIN ST
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City | LAKEVILLE
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State | CT
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Zip | 06039-1204
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Country | US
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Telephone | 860-435-3551
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Fax | 860-435-3561
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Provider Business Mailing Address
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Address Line | PO BOX 1748
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City | LAKEVILLE
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State | CT
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Zip | 06039-1748
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Country | US
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Telephone | 860-435-3551
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Fax | 860-435-3561
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL J KELLY
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Credential | MD
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Telephone | 860-435-3551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 041727
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License Number State | CT
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