MEDICARE: MAUREEN A KELLY MD PLLC

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	2080A0000X	Pediatric Adolescent Medicine Physician	4301056543	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
2	1015775	OTHER	MI	HEALTH ADVANTAGE
3	350F302120	OTHER	MI	BC GROUP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	350F302120	OTHER	MI	BCN GROUP

General Provider Information

NPI Number	:	1700884814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAUREEN A KELLY MD PLLC

Provider Business Mailing Address
First Line	:	PO BOX 44047
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48244-0047
Country	:	US
Telephone Number	:	248-451-0600
Fax Number	:	248-451-0700

Provider Business Practice Location Address
First Line	:	43205 WOODWARD AVE
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5006
Country	:	US
Telephone Number	:	248-451-0600
Fax Number	:	248-451-0700

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. MAUREEN KELLY
Credential	:	MD
Telephone Number	:	248-451-0600

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	06/24/2010

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