Provider Demographics
NPI:1164519005
Name:KELLY, WAYNE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:DAVID
Last Name:KELLY
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 1:1883 HICKS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1254
Mailing Address - Country:US
Mailing Address - Phone:847-359-9432
Mailing Address - Fax:888-687-1245
Practice Address - Street 1:1883 HICKS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1254
Practice Address - Country:US
Practice Address - Phone:847-359-9432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078457208VP0014X
IL360784572084P2900X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078457OtherSTATE OF IL LICENSE
ILK13255Medicare ID - Type UnspecifiedLOCALITY 16
ILK39001Medicare PIN
ILK16222Medicare ID - Type UnspecifiedJPCC ANCILLARY PROVIDERS
ILK13256Medicare ID - Type UnspecifiedLOCALITY 99
ILK16223Medicare ID - Type UnspecifiedJOLIET PHYSICIANS ONLY
F13947Medicare UPIN
ILK13254Medicare ID - Type Unspecified