1689933467 NPI number — JEFFERY S KELLEY MD

Table of content: (NPI 1689933467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689933467 NPI number — JEFFERY S KELLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERY S KELLEY MD
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:
1689933467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32565-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-675-4546
Provider Business Mailing Address Fax Number:
850-675-4548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14088 ALABAMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32565-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-675-4546
Provider Business Practice Location Address Fax Number:
850-675-4548
Provider Enumeration Date:
05/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
850-675-4546

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME81689 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009952450 . This is a "ALACAID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 7032394 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 59037346 . This is a "BLUE CROSS AND BLUE SHIELD OF ALABAMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 591032244 . This is a "CHAMPVA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00017883 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 261059100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4071564 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: A611 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05101 . This is a "BLUE CROSS AND BLUE SHIELD OF FLORIDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1203400 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2239990 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 591032244 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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