Provider Demographics
NPI:1295726628
Name:KELLY, JOHN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S EVANS ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1949
Mailing Address - Country:US
Mailing Address - Phone:517-423-9300
Mailing Address - Fax:517-423-9400
Practice Address - Street 1:115 S EVANS ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1949
Practice Address - Country:US
Practice Address - Phone:517-423-9300
Practice Address - Fax:517-423-9400
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0804610981OtherBCBS
MI4301057968OtherSTATE LICENSE
MI4301057968OtherSTATE LICENSE
MIP48280001Medicare PIN