MEDICARE: MICHAEL KELLEY DPM

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	213E00000X	Podiatrist	5901001533	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548376494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL KELLEY DPM

Provider Business Mailing Address
First Line	:	4310 LEONARD ST NW
Second Line	:	SUITE 103
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-8447
Country	:	US
Telephone Number	:	616-453-6329
Fax Number	:	616-453-1725

Provider Business Practice Location Address
First Line	:	6785 MYERS LAKE AVE NE
Second Line	:	SUITE C
City	:	ROCKFORD
State	:	MI
Zip	:	49341-7416
Country	:	US
Telephone Number	:	616-874-8772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	10/12/2009

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