Provider Demographics
NPI:1396766937
Name:KELLY, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1820 WEST THIRD STREET
Mailing Address - Street 2:GENESIS HEALTH GROUP
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52802-0000
Mailing Address - Country:US
Mailing Address - Phone:563-421-0500
Mailing Address - Fax:563-326-1901
Practice Address - Street 1:1820 W 3RD ST
Practice Address - Street 2:GENESIS HEALTH GROUP
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-1812
Practice Address - Country:US
Practice Address - Phone:563-421-0500
Practice Address - Fax:563-326-1901
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-02-15
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Provider Licenses
StateLicense IDTaxonomies
IL036-079295207Q00000X
IA24314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019320OtherPHYSICIANS PLUS
390808509DXOtherUNITY
14313OtherDEAN HEALTH PLAN
390808509OtherCIGNA
390808509DXOtherUNITY