Provider Demographics
NPI:1053793208
Name:KELLY, MICK (MD)
Entity type:Individual
Prefix:
First Name:MICK
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:N15W28300 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4800
Mailing Address - Country:US
Mailing Address - Phone:262-303-5055
Mailing Address - Fax:262-303-5057
Practice Address - Street 1:N15W28300 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4800
Practice Address - Country:US
Practice Address - Phone:262-303-5055
Practice Address - Fax:262-303-5057
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125066593207X00000X
UT11729390-1205207XS0114X
WI75716207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery