Provider Demographics
NPI:1114069549
Name:ELEANOR KELLY, MD, INC
Entity Type:Organization
Organization Name:ELEANOR KELLY, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-735-0174
Mailing Address - Street 1:5100 BIRCH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2160
Mailing Address - Country:US
Mailing Address - Phone:949-735-0174
Mailing Address - Fax:949-854-7143
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-735-0174
Practice Address - Fax:949-854-7143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA064544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH28231Medicare UPIN
CT110008963Medicare ID - Type Unspecified