Provider Demographics
NPI:1164416228
Name:KELLY, CARMEL M (MD)
Entity Type:Individual
Prefix:
First Name:CARMEL
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2100
Mailing Address - Country:US
Mailing Address - Phone:781-963-0676
Mailing Address - Fax:781-963-7417
Practice Address - Street 1:1093 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2100
Practice Address - Country:US
Practice Address - Phone:781-963-0676
Practice Address - Fax:781-963-7417
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100052OtherEVERCARE
NE0100918OtherUNITED HLTHCARE OF NE
3567516OtherAETNA HEALTH PLAN
043243146OtherUNICARE
21003084366OtherBEECH STREET
J06362OtherBLUE CARE ELECT
M15986OtherBLUE CROSS INDEMNITY
7134757002OtherCIGNA
J06362OtherHMO BLUE
043243146OtherHCVM
043243146OtherGREAT WEST HEALTHCARE
64506OtherHARVARD PILGRIM
043243146OtherHARVARD PILGRIM
MA3022447Medicaid
J06362OtherBLUE CROSS INDEMNITY
080156922Medicare ID - Type UnspecifiedRR
21003084366OtherBEECH STREET
043243146Medicare ID - Type UnspecifiedPREFERRED TUFTS
7134757002OtherCIGNA
043243146OtherUNICARE