Provider Demographics
NPI:1609874064
Name:KELLY, MAUREEN A (MD)
Entity type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
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 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-451-0600
Mailing Address - Fax:248-451-0700
Practice Address - Street 1:43205 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5006
Practice Address - Country:US
Practice Address - Phone:248-451-0600
Practice Address - Fax:248-451-0700
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056543208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4183802Medicaid
MI4183802Medicaid