Provider Demographics
NPI:1104861343
Name:KELLY, JAMES M (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1635 W MAIN ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-1119
Mailing Address - Country:US
Mailing Address - Phone:717-738-0660
Mailing Address - Fax:717-738-0658
Practice Address - Street 1:1635 W MAIN ST
Practice Address - Street 2:SUITE 700
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1119
Practice Address - Country:US
Practice Address - Phone:717-738-0660
Practice Address - Fax:717-738-0658
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD428418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107754 S1QFOtherGEISINGER HEALTH PLAN
PA1429961OtherAETNA HMO
PA50061893OtherCAPITAL BLUE CROSS
PA50060203OtherCAPITAL BLUE CROSS
PA1874597OtherHIGHMARK BLUE SHIELD
PAP008054OtherGATEWAY HEALTH PLAN
PA7276819OtherAETNA NON-HMO
PAI54742OtherHEALTH ASSURANCE
PA50061968OtherCAPITAL BLUE CROSS
PA50065832OtherCAPITAL BLUE CROSS
PA1016458260001Medicaid
PA107754 S1QFOtherGEISINGER HEALTH PLAN
PA50065832OtherCAPITAL BLUE CROSS
PAI54742Medicare UPIN
PA102011JZEMedicare PIN