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General NPI Number Information
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NPI Number | 1952889073
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Entity Type | Organization
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Legal Business Name | KELLY MCGREGORY PEDIATRICS LLC
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Dates
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Enumeration Date | 07/31/2018
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Last Update Date | 09/20/2018
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Provider Practice Location Address
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Address Line | 6000 BASS LAKE RD STE 102
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City | CRYSTAL
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State | MN
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Zip | 55429
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Country | US
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Telephone | 815-975-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 6000 BASS LAKE RD STE 102
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City | CRYSTAL
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State | MN
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Zip | 55429-2768
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Country | US
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Telephone | 763-334-5151
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Fax | 612-324-7445
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Authorized Official
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Title or Position | PEDIATRICIAN
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Name | DR. KELLY MCGREGORY
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Credential | DO
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Telephone | 763-334-5151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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