1538899364 NPI number — DR. JAYLYN ROSE KELLY MD

Table of content: DR. JAYLYN ROSE KELLY MD (NPI 1538899364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538899364 NPI number — DR. JAYLYN ROSE KELLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
JAYLYN
Provider Middle Name:
ROSE
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:
1538899364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPARTMENT OF FAMILY MEDICINE
Provider Second Line Business Mailing Address:
300 NORTH INGALLS BUILDING, RM. NI4C06
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14700 E OLD US HIGHWAY 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHELSEA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48118-1185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-475-1321
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2022

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: 390200000X , with the licence number:  4351049000 , 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)





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