Provider Demographics
NPI:1235139130
Name:KELLY, MARYBETH S (PAC)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:MARYBETH
Other - Middle Name:S
Other - Last Name:MARKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:75 SPRINGFIELD RD
Mailing Address - Street 2:SUITE 1 FAMILY MEDICINE ASSOC
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085
Mailing Address - Country:US
Mailing Address - Phone:413-562-5173
Mailing Address - Fax:413-562-1716
Practice Address - Street 1:75 SPRINGFIELD RD
Practice Address - Street 2:SUITE 1 FAMILY MEDICINE ASSOC
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085
Practice Address - Country:US
Practice Address - Phone:413-562-5173
Practice Address - Fax:413-562-1716
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
011500OtherCONNECTICARE OF MA
21237210422OtherBEECH STREET
MAAP1267Medicare ID - Type Unspecified
011500OtherCONNECTICARE OF MA