Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN1001X | Nutrition | JK008789 | MI |
Y | 111NR0200X | Radiology | JK008789 | MI |
Y | 213ER0200X | Radiology | JK008789 | MI |
NPI | 1932159928 |
---|---|
Provider Name | Dr. Jeffrey Alan Kelly |
First Address | Saginaw, MI 48609-9616 |
Second Address | Saginaw, MI 48603-4028 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2006 |
Last Update Date | 01/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0G30188 | BCBS PIN (01) | MI |
0N24830 | MEDICARE ID (01) | MI |
950G311530 | BCBS PIN NUMBER (01) | MI |
JK008789 | BCBS LICENSE NUMBER (01) | MI |
T3355 | (02) | MI |