MEDICARE: JOHN J KELLY MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	4301057968	MI

General Provider Information

NPI Number	:	1134301880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN J KELLY MD PC

Provider Business Mailing Address
First Line	:	3124 SUNNYWOOD DR
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-2063
Country	:	US
Telephone Number	:	734-929-9451
Fax Number	:

Provider Business Practice Location Address
First Line	:	3606 W LIBERTY RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-9049
Country	:	US
Telephone Number	:	734-929-9451
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JOHN J KELLY
Credential	:	MD PC
Telephone Number	:	517-423-9300

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	12/04/2007

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