1265583884 NPI number — MICHAEL KELLY D.O.

Table of content: MICHAEL KELLY D.O. (NPI 1265583884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265583884 NPI number — MICHAEL KELLY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1265583884
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
776 NORTHFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-736-1939
Provider Business Mailing Address Fax Number:
973-736-1937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
776 NORTHFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-736-1939
Provider Business Practice Location Address Fax Number:
973-736-1937
Provider Enumeration Date:
01/12/2007

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: 207RS0010X , with the licence number:  25MB07620900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 203812206 . This is a "TAX ID FOR SECOND OFFICE NJ SPORTS MEDICINE CENTER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7331613 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1619025038 . This is a "MEDICARE PIN SECOND OFFICE GROUP NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3389558 . This is a "OXFORD PROVIDER NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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