1306078225 NPI number — WILLIAM M. KELLY M.D., INC.

Table of content: (NPI 1306078225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306078225 NPI number — WILLIAM M. KELLY M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM M. KELLY M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1306078225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44489 TOWN CENTER WAY
Provider Second Line Business Mailing Address:
SUITE D BOX 540
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-2789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-776-8001
Provider Business Mailing Address Fax Number:
760-836-3934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
72980 FRED WARING DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-2898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-776-8001
Provider Business Practice Location Address Fax Number:
760-836-3934
Provider Enumeration Date:
08/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
TANIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING/CONTRAC ADMINISTRATOR
Authorized Official Telephone Number:
760-776-8001

Provider Taxonomy Codes

  • Taxonomy code: 2085D0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: A34125 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A341250 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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