Provider Demographics
NPI:1063449130
Name:KELLY, MICHAEL THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6707 BRENTWOOD STAIR RD STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3368
Mailing Address - Country:US
Mailing Address - Phone:817-284-9850
Mailing Address - Fax:817-720-9892
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7474
Practice Address - Country:US
Practice Address - Phone:817-284-9850
Practice Address - Fax:817-720-9892
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-019092081P0004X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919524Medicaid
NC5919524Medicaid
VAE32774Medicare UPIN