Provider Demographics
NPI:1558587675
Name:KELLEY, HARLEY (MD)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:
Last Name:KELLEY
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 1:63594 J D ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8870
Mailing Address - Country:US
Mailing Address - Phone:541-382-8625
Mailing Address - Fax:
Practice Address - Street 1:557 W WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1441
Practice Address - Country:US
Practice Address - Phone:541-573-7281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD06122208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101345Medicaid
C93302Medicare UPIN
02ZGBDTAMedicare ID - Type Unspecified