=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841348240
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN MICHAEL KELLY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 RENAISSANCE TOWNE DR SUITE 310
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-295-5581
-----------------------------------------------------
Fax | 801-295-9253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2255 N 1700 W SUITE 200
-----------------------------------------------------
City | LAYTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84041-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-776-2180
-----------------------------------------------------
Fax | 801-776-2534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YP0228X
-----------------------------------------------------
Taxonomy Name | Pediatric Otolaryngology Physician
-----------------------------------------------------
License Number | 182660-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------