Provider Demographics
NPI:1518199306
Name:KELLY, WILLIAM ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALBERT
Last Name:KELLY
Suffix:
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 1:8820 LADUE RD.
Mailing Address - Street 2:SUITE 309
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124
Mailing Address - Country:US
Mailing Address - Phone:314-754-3245
Mailing Address - Fax:
Practice Address - Street 1:8820 LADUE RD.
Practice Address - Street 2:SUITE 309
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124
Practice Address - Country:US
Practice Address - Phone:314-754-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO309342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000001028Medicare UPIN