Provider Demographics
NPI:1093805087
Name:KELLY, WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3800 S NATIONAL AVE
Mailing Address - Street 2:#540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5209
Mailing Address - Country:US
Mailing Address - Phone:417-269-1940
Mailing Address - Fax:417-269-1948
Practice Address - Street 1:941 E HUBBLE DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2538
Practice Address - Country:US
Practice Address - Phone:417-269-1940
Practice Address - Fax:417-269-1948
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107908OtherBCMO
MO208663419Medicaid
MO208663419Medicaid
G43729Medicare UPIN
163050038Medicare PIN