Provider Demographics
NPI:1245431105
Name:SHIPPEY, KELLEY FORD III (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:FORD
Last Name:SHIPPEY
Suffix:III
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 1:350 HERITAGE WAY STE 2100
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3167
Mailing Address - Country:US
Mailing Address - Phone:406-257-8992
Mailing Address - Fax:406-257-8996
Practice Address - Street 1:350 HERITAGE WAY STE 2100
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3167
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-257-8996
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC353542080S0012X, 207R00000X, 207RS0012X
MTMED-PHYS-LIC-703372080S0012X, 207RS0012X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC353548Medicaid
SCSC03627951Medicare PIN