1487189874 NPI number — P.A. KELLY MD PLLC

Table of content: (NPI 1487189874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487189874 NPI number — P.A. KELLY MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
P.A. KELLY MD PLLC
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:
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:
1487189874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6011
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59806-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-541-1400
Provider Business Mailing Address Fax Number:
406-541-1401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 TINA AVE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59808-1581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-541-1400
Provider Business Practice Location Address Fax Number:
406-541-1401
Provider Enumeration Date:
04/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MADZELONKA
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRAC
Authorized Official Telephone Number:
406-541-1400

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  11020 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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