MEDICARE: BETH A KELLEY NP, CNM

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	363L00000X	Nurse Practitioner	4704194227	MI
2	363LF0000X	Family Nurse Practitioner	4704194227	MI
3	367A00000X	Advanced Practice Midwife	4704194227	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000612032	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	160G510560	OTHER	MI	BCBS GROUP-WOMENS SERVICES
4	700G560080	OTHER	MI	BCBS GROUP-THREE RIVERS HEALTH

General Provider Information

NPI Number	:	1972724821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH A KELLEY NP, CNM

Provider Business Mailing Address
First Line	:	1717 E CHICAGO RD
Second Line	:
City	:	STURGIS
State	:	MI
Zip	:	49091-8524
Country	:	US
Telephone Number	:	269-659-6747
Fax Number	:	269-659-6746

Provider Business Practice Location Address
First Line	:	1717 E. CHICAGO ROAD
Second Line	:
City	:	STURGIS
State	:	MI
Zip	:	49091-2372
Country	:	US
Telephone Number	:	269-659-6747
Fax Number	:	269-659-6746

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	12/06/2012

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