Provider Demographics
NPI:1124014758
Name:KELLY, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12361 W BOLA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:623-584-5626
Mailing Address - Fax:623-584-8998
Practice Address - Street 1:12361 W BOLA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-584-5626
Practice Address - Fax:623-584-8998
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ27172207X00000X
AZ35083207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5920416OtherAETNA
AZP00188666OtherRAILROAD MEDICARE
AZ2036792OtherUNITED HEALTHCARE
AZ2Z1651OtherHEALTHNET
AZ1124014758OtherAHCCCS
AZP0836100OtherBCBS OUT OF AREA
AZ514829Medicaid
AZZWCLCJMedicare PIN
AZ100683Medicare PIN
AZ2Z1651OtherHEALTHNET
AZP00188666OtherRAILROAD MEDICARE