1437135936 NPI number — AMY ELIZABETH KELLY MD

Table of content: AMY ELIZABETH KELLY MD (NPI 1437135936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437135936 NPI number — AMY ELIZABETH KELLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
AMY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1437135936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 EXCHANGE ST W
Provider Second Line Business Mailing Address:
NUMBER 622
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55102-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-227-9141
Provider Business Mailing Address Fax Number:
651-265-6772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 BEAM AVE
Provider Second Line Business Practice Location Address:
NUMBER 102
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-1163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-770-1385
Provider Business Practice Location Address Fax Number:
651-770-0672
Provider Enumeration Date:
12/16/2005

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: 207V00000X , with the licence number:  46573 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0703794 . This is a "MEDICA CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0703794 . This is a "MEDICA PRIMARY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2130657 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 826SOKE . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00199150 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP42083 . This is a "EMHD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 960981041136 . This is a "PREICH PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 960981041136 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0703794 . This is a "SELECT CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34495100 . This is a "WISCONSIN MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 960981041136 . This is a "PEAK PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




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