Individual
MICHAEL KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
622 EAGLE ROCK AVE, SUITE 305, WEST ORANGE, NJ 07052
(973) 736-1939
(973) 736-1937
Mailing address
622 EAGLE ROCK AVE, SUITE 305, WEST ORANGE, NJ 07052
(973) 736-1939
(973) 736-1937
Taxonomy
Speciality
Code
Description
License number
State
207RS0010X
Sports Medicine (Internal Medicine) Physician
Primary
25MB07620900
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1619025038
MEDICARE PIN SECOND OFFICE GROUP NUMBER
NJ
01
—
203812206
TAX ID FOR SECOND OFFICE NJ SPORTS MEDICINE CENTER
NJ
01
—
7331613
AETNA PROVIDER NUMBER
NJ
01
—
P3389558
OXFORD PROVIDER NUMBER
NJ
Enumeration date
01/12/2007
Last updated
03/16/2026
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