Provider Demographics
NPI:1134102346
Name:KELLEY, ERIC (MD)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
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 1:2215 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-4728
Mailing Address - Country:US
Mailing Address - Phone:708-344-7171
Mailing Address - Fax:708-344-0319
Practice Address - Street 1:2215 17TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-4728
Practice Address - Country:US
Practice Address - Phone:708-344-7171
Practice Address - Fax:708-344-0319
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3657671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03605761Medicaid
IL650060Medicare ID - Type Unspecified
IL03605761Medicaid