Provider Demographics
NPI:1043349608
Name:KELLY, JEREMIAH F (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:SENIOR HEALTH CLINIC UNM
Mailing Address - Street 2:1101 MEDICAL ARTS AVE NE
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-6082
Mailing Address - Fax:505-272-7782
Practice Address - Street 1:SENIOR HEALTH CLINIC UNM
Practice Address - Street 2:1101 MEDICAL ARTS AVE NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-6082
Practice Address - Fax:505-272-7782
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2011-06-10
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Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0248207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA47268Medicare UPIN