Provider Demographics
NPI:1083662605
Name:KELLEY, WILLIAM EDWIN JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWIN
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 THREE CHOPT RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4601
Mailing Address - Country:US
Mailing Address - Phone:804-285-9416
Mailing Address - Fax:804-285-9461
Practice Address - Street 1:8921 THREE CHOPT RD
Practice Address - Street 2:SUITE 300
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4601
Practice Address - Country:US
Practice Address - Phone:804-285-9416
Practice Address - Fax:804-285-9461
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032187174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083662605Medicaid
VA007391650Medicaid
VA023133H43Medicare PIN
BO6642Medicare UPIN
021949912Medicare ID - Type Unspecified