Provider Demographics
NPI:1003909532
Name:PHILLIP W. KELLY, MD, PA
Entity Type:Organization
Organization Name:PHILLIP W. KELLY, MD, PA
Other - Org Name:NORTH TEXAS OPHTHALMOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-723-1274
Mailing Address - Street 1:PO BOX 8169
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76307-8169
Mailing Address - Country:US
Mailing Address - Phone:940-723-1274
Mailing Address - Fax:940-723-1525
Practice Address - Street 1:1704 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5020
Practice Address - Country:US
Practice Address - Phone:940-723-1274
Practice Address - Fax:940-723-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0877580001Medicare NSC
TX00F76LMedicare ID - Type UnspecifiedELECTRONIC MEDICARE NUMBE