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General NPI Number Information
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NPI Number | 1598071201
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Entity Type | Individual
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Provider Name | THOMAS KELLY
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Gender | Male
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Dates
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Enumeration Date | 08/19/2010
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Last Update Date | 01/13/2020
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Provider Practice Location Address
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Address Line | 850 W BARAGA AVE STE 32
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City | MARQUETTE
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State | MI
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Zip | 49855-4550
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Country | US
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Telephone | 906-449-3680
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Fax |
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Provider Business Mailing Address
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Address Line | 1025 MOREHEAD MEDICAL DR
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City | CHARLOTTE
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State | NC
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Zip | 28204-2963
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Country | US
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Telephone |
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Fax |
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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 | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 4301500343
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License Number State | MI
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