Provider Demographics
NPI:1376646588
Name:KELLEY, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:KELLEY
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 1:1050 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8121
Mailing Address - Country:US
Mailing Address - Phone:970-298-5864
Mailing Address - Fax:970-298-5888
Practice Address - Street 1:1050 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8121
Practice Address - Country:US
Practice Address - Phone:970-298-5864
Practice Address - Fax:970-298-5888
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17526207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01175264Medicaid
UTZ0257Medicaid
UTZ0257Medicaid
COC322408Medicare PIN
COC273028Medicare PIN