Provider Demographics
NPI:1548376494
Name:KELLEY, MICHAEL (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:6785 MYERS LAKE AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7416
Practice Address - Country:US
Practice Address - Phone:616-874-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001533213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2751473Medicaid
MI2751473Medicaid
MI0483980001Medicare NSC
MIT92545Medicare UPIN