1336402452 NPI number — DR. ROBERT C KELLY M.D.

Table of content: DR. ROBERT C KELLY M.D. (NPI 1336402452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336402452 NPI number — DR. ROBERT C KELLY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
ROBERT
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
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:
1336402452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 PORTSMOUTH AVE, SUITE 1 #149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATHAM
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-242-7799
Provider Business Mailing Address Fax Number:
567-232-3241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 HAMPTON RD BLDG 32ND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EXETER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03833-4831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-775-0000
Provider Business Practice Location Address Fax Number:
603-755-0247
Provider Enumeration Date:
06/22/2012

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: 208M00000X , with the licence number:  16913 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 16913 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3102686 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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