Provider Demographics
NPI:1396703450
Name:KELLY, KEVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC ALLERGY/IMMUNOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-607-5280
Mailing Address - Fax:414-266-6849
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC ALLERGY/IMMUNOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-607-5280
Practice Address - Fax:414-266-6849
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-12-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI224202080P0201X
MO2005026718208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396703450Medicaid
MO207550708Medicaid
WI680860581Medicare PIN
MO207550708Medicaid
WI1396703450Medicaid
WI736011566Medicare PIN