1144264573 NPI number — DR. KATHLEEN MARIE KELLY AU.D.

Table of content: DR. KATHLEEN MARIE KELLY AU.D. (NPI 1144264573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144264573 NPI number — DR. KATHLEEN MARIE KELLY AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
KATHLEEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIRCHFIELD
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
AU.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144264573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 N US HIGHWAY 31
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETOSKEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49770-9305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-489-1006
Provider Business Mailing Address Fax Number:
231-753-3039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 SUMMIT PARK DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PETOSKEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49770-8774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-347-1800
Provider Business Practice Location Address Fax Number:
231-347-1864
Provider Enumeration Date:
06/15/2006

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: 231H00000X , with the licence number:  1601000052 , 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: 640B410780 . This is a "BCBS AUDIOLOGYPROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 540B410790 . This is a "BCBS HEARING PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".