Provider Demographics
NPI:1366472177
Name:THE KELLY EYE CENTER PA
Entity Type:Organization
Organization Name:THE KELLY EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-282-1100
Mailing Address - Street 1:8851 ELLSTREE LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-2045
Mailing Address - Country:US
Mailing Address - Phone:919-282-1100
Mailing Address - Fax:919-282-1119
Practice Address - Street 1:8851 ELLSTREE LN
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-2045
Practice Address - Country:US
Practice Address - Phone:919-282-1100
Practice Address - Fax:919-282-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013HCMedicaid
NC2326977Medicare ID - Type Unspecified
NC89013HCMedicaid