1154368199 NPI number — SAMUEL K KELLEY M.D.

Table of content: SAMUEL K KELLEY M.D. (NPI 1154368199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154368199 NPI number — SAMUEL K KELLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
SAMUEL
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1154368199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 MYSTIC AVE STE 6
Provider Second Line Business Mailing Address:
C/O JUDY DONNELLY - DCS MENTAL HEALT
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-877-8292
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 MYSTIC AVE STE 6
Provider Second Line Business Practice Location Address:
C/O JUDY DONNELLY - DCS MENTAL HEALT
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-877-8292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2006

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: 2084P0804X , with the licence number:  72427 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1154368199 . This is a "NPI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 107342200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".