Provider Demographics
NPI:1346242831
Name:KELLY, PAUL E (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
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 1:660 WHITE PLAINS RD FL 4
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5139
Mailing Address - Country:US
Mailing Address - Phone:914-984-2546
Mailing Address - Fax:
Practice Address - Street 1:400 OLD COUNTRY ROAD
Practice Address - Street 2:SUITE 16
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2145
Practice Address - Country:US
Practice Address - Phone:631-574-3419
Practice Address - Fax:631-727-8110
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230368207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646179Medicaid
NYP0108756OtherRAILROAD MEDICARE PIN
NYA400050159Medicare PIN
NY02646179Medicaid