1013951953 NPI number — DR. JULIE L HENRY-KELLY MD

Table of content: DR. JULIE L HENRY-KELLY MD (NPI 1013951953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013951953 NPI number — DR. JULIE L HENRY-KELLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY-KELLY
Provider First Name:
JULIE
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013951953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27427 SCHOENHERR RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48088-4729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-754-4417
Provider Business Mailing Address Fax Number:
586-754-4473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27427 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48088-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-754-4417
Provider Business Practice Location Address Fax Number:
586-754-4473
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  4301066091 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4492165 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4876080001 . This is a "NATL SUPPLIER CLEARINGHOU" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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