Provider Demographics
NPI:1588634802
Name:KELLY, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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:BUILDING 9040 FITZSIMMONS BLVD
Mailing Address - Street 2:MADIGAN ARMY MEDICAL CENTER
Mailing Address - City:FORT LEWIS
Mailing Address - State:WA
Mailing Address - Zip Code:98431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 FITZSIMMONS BLVD
Practice Address - Street 2:MADIGAN ARMY MEDICAL CENTER
Practice Address - City:FORT LEWIS
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE23252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine