Provider Demographics
NPI:1427032119
Name:KELLEY, COLLEEN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:KELLEY
Suffix:
Gender:F
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:PO BOX 1434
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1434
Mailing Address - Country:US
Mailing Address - Phone:802-447-3520
Mailing Address - Fax:802-447-3520
Practice Address - Street 1:1300 MASSACHUSETTS AVE
Practice Address - Street 2:EMERGENCY DEPT ST MARYS HOSPITAL
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1628
Practice Address - Country:US
Practice Address - Phone:518-268-5697
Practice Address - Fax:518-268-5766
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2140431207P00000X
MA160480207P00000X
VT0420008624207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01975837Medicaid
VN0506Medicare ID - Type Unspecified
NY01975837Medicaid
F27853Medicare UPIN