Provider Demographics
NPI:1124102546
Name:KELLY, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06068-0585
Mailing Address - Country:US
Mailing Address - Phone:860-435-3551
Mailing Address - Fax:860-435-3561
Practice Address - Street 1:16 CONKLIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:CT
Practice Address - Zip Code:06068-1823
Practice Address - Country:US
Practice Address - Phone:860-435-3551
Practice Address - Fax:860-435-3561
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001417270Medicaid
1376703751OtherNPI GROUP NUMBER
CT001417270Medicaid
CT110009045Medicare ID - Type Unspecified