Provider Demographics
NPI:1578655528
Name:ROBERT W. KELLEY ODPC
Entity Type:Organization
Organization Name:ROBERT W. KELLEY ODPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-827-4327
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873-0399
Mailing Address - Country:US
Mailing Address - Phone:406-827-4327
Mailing Address - Fax:406-827-3027
Practice Address - Street 1:401 MAIN STREET
Practice Address - Street 2:
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873-0399
Practice Address - Country:US
Practice Address - Phone:406-827-4327
Practice Address - Fax:406-827-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT26620OtherBLUE CROSS/BLUE SHIELD MT
MT048-3119Medicaid
MT0642010001OtherDME MEDICARE
MT26620OtherBLUE CROSS/BLUE SHIELD MT
MT0642010001Medicare NSC