Provider Demographics
NPI:1467495226
Name:KELLY MEDICAL, PC
Entity Type:Organization
Organization Name:KELLY MEDICAL, PC
Other - Org Name:KELLY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-752-9600
Mailing Address - Street 1:PO BOX 268938
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8938
Mailing Address - Country:US
Mailing Address - Phone:405-752-9600
Mailing Address - Fax:405-752-9650
Practice Address - Street 1:13921 N MERIDIAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1106
Practice Address - Country:US
Practice Address - Phone:405-752-9600
Practice Address - Fax:405-752-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522374Medicare ID - Type Unspecified
OKH06214Medicare UPIN
6370240001Medicare NSC