Provider Demographics
NPI:1124464268
Name:VIRGIN, KELLI LYNNE (DO)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNNE
Last Name:VIRGIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1822
Mailing Address - Country:US
Mailing Address - Phone:906-253-0113
Mailing Address - Fax:586-582-6631
Practice Address - Street 1:11855 E 12 MILE RD STE 400
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3471
Practice Address - Country:US
Practice Address - Phone:586-586-6630
Practice Address - Fax:586-582-6631
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020536207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine