Provider Demographics
NPI:1093876609
Name:KELLEY, ROBERT LONG (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LONG
Last Name:KELLEY
Suffix:
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:BOX 620359
Mailing Address - Street 2:
Mailing Address - City:NEWTON LOWER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02462
Mailing Address - Country:US
Mailing Address - Phone:781-891-4909
Mailing Address - Fax:
Practice Address - Street 1:20 HOPE AVE SUITE 201
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:20453
Practice Address - Country:US
Practice Address - Phone:781-891-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247542084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMK0074803ARMedicaid
MAKEB23028Medicare ID - Type Unspecified
MAMK0074803ARMedicaid