Provider Demographics
NPI:1407030760
Name:BRIAN W KELLY MD PC
Entity Type:Organization
Organization Name:BRIAN W KELLY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-640-5950
Mailing Address - Street 1:545 SE OAK ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4147
Mailing Address - Country:US
Mailing Address - Phone:503-640-5950
Mailing Address - Fax:503-648-3140
Practice Address - Street 1:545 SE OAK ST
Practice Address - Street 2:SUITE F
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4147
Practice Address - Country:US
Practice Address - Phone:503-640-5950
Practice Address - Fax:503-648-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10756207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDG4207OtherGBA RAILROAD MEDICARE
OR213070Medicaid
OR213070Medicaid