Provider Demographics
NPI:1073626453
Name:KELLY, WILLIAM SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:SAMUEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9600 VETERANS DR SW
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-0003
Mailing Address - Country:US
Mailing Address - Phone:253-583-1698
Mailing Address - Fax:253-589-4167
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0003
Practice Address - Country:US
Practice Address - Phone:253-583-1698
Practice Address - Fax:253-589-4167
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA335482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2009646Medicaid
WAG8891457OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON