Provider Demographics
NPI:1407807613
Name:KELL, THORNTON JR (MD)
Entity Type:Individual
Prefix:
First Name:THORNTON
Middle Name:
Last Name:KELL
Suffix:JR
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 1:1107 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3237
Mailing Address - Country:US
Mailing Address - Phone:781-444-8046
Mailing Address - Fax:
Practice Address - Street 1:1107 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-3237
Practice Address - Country:US
Practice Address - Phone:781-444-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0364522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2023555Medicaid
MAC23038Medicare ID - Type Unspecified
MA2023555Medicaid