Provider Demographics
NPI:1023036431
Name:KELLY, RICHARD AMADEUS (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:AMADEUS
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6312
Mailing Address - Country:US
Mailing Address - Phone:724-779-4334
Mailing Address - Fax:724-779-4399
Practice Address - Street 1:730 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-6312
Practice Address - Country:US
Practice Address - Phone:724-779-4334
Practice Address - Fax:724-779-4399
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAJ-007107-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA568795OtherHIGHMARK BLUE CROSS
PA568795OtherHIGHMARK BLUE CROSS