Provider Demographics
NPI:1497069660
Name:WILLIAM M. KELLY M.D., INC.
Entity Type:Organization
Organization Name:WILLIAM M. KELLY M.D., INC.
Other - Org Name:HEALTH SCAN IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-776-8001
Mailing Address - Street 1:44489 TOWN CENTER WAY
Mailing Address - Street 2:SUITE D BOX 540
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-2723
Mailing Address - Country:US
Mailing Address - Phone:760-776-9777
Mailing Address - Fax:760-776-4999
Practice Address - Street 1:425 DIAMOND DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4495
Practice Address - Country:US
Practice Address - Phone:951-245-2700
Practice Address - Fax:951-245-2770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM M. KELLY M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-30
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA341252085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27387Medicare UPIN
CAZZZ22856ZMedicare PIN