Provider Demographics
NPI:1649343278
Name:KELLY, MICHAEL JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
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 1:1708 YAKIMA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5309
Mailing Address - Country:US
Mailing Address - Phone:253-363-8700
Mailing Address - Fax:360-782-3115
Practice Address - Street 1:1708 YAKIMA AVE STE 300
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5309
Practice Address - Country:US
Practice Address - Phone:253-363-8700
Practice Address - Fax:360-782-3115
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033879207R00000X, 208M00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0280978OtherL&I
WA1045078Medicaid
WA8193823Medicaid
WAG8901118OtherMEDICARE
WA0125746OtherSTATE L&I
WAG8901118OtherMEDICARE
WA0280978OtherL&I
WAG8901118OtherMEDICARE