MEDICARE: DR. MICHAEL KELLY MD

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	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	86418	WI
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	4301065795	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BLUE CROSS	OTHER	MI	340H275000
2	COMMERICAL	OTHER	MI	382032989

General Provider Information

NPI Number	:	1912981010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL KELLY MD

Provider Business Mailing Address
First Line	:	1933 HYLAND ST
Second Line	:
City	:	FERNDALE
State	:	MI
Zip	:	48220-3803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1933 HYLAND ST
Second Line	:
City	:	FERNDALE
State	:	MI
Zip	:	48220-3803
Country	:	US
Telephone Number	:	248-933-0558
Fax Number	:

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

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	03/20/2026

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Directions to “ DR. MICHAEL KELLY MD” Practice Location

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