Provider Demographics
NPI:1376715516
Name:MAUREEN A KELTY MD PC
Entity Type:Organization
Organization Name:MAUREEN A KELTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-671-2425
Mailing Address - Street 1:3015 SQUALICUM PKWY
Mailing Address - Street 2:#280
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1945
Mailing Address - Country:US
Mailing Address - Phone:360-671-2425
Mailing Address - Fax:360-671-1470
Practice Address - Street 1:3015 SQUALICUM PKWY
Practice Address - Street 2:#280
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1945
Practice Address - Country:US
Practice Address - Phone:360-671-2425
Practice Address - Fax:360-671-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1071497Medicaid
WA1071497Medicaid
8854693Medicare PIN