1780666560 NPI number — WILLIAM R KELLEY JR. MD

Table of content: WILLIAM R KELLEY JR. MD (NPI 1780666560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780666560 NPI number — WILLIAM R KELLEY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
WILLIAM
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1780666560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4825 HWY 95
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MOHAVE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86426-8315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-326-7225
Provider Business Mailing Address Fax Number:
760-326-8867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9330 STATE ROAD 54
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRINITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34655-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-399-5800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2005

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: 2085R0202X , with the licence number:  27770 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: C51795 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 159835 , 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: 914673 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00C517950 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100505339 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116923600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com