Provider Demographics
NPI:1376606830
Name:KELLEY, MICHAEL BRYANT (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRYANT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-691-8070
Mailing Address - Fax:270-691-8026
Practice Address - Street 1:1301 PLEASANT VALLEY RD STE 202
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-417-7500
Practice Address - Fax:270-417-7509
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA60212959207RC0000X
TNMD43981207RC0000X
KY52292207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid