Provider Demographics
NPI:1598810814
Name:RUSSELL S KELLY MD LLC
Entity Type:Organization
Organization Name:RUSSELL S KELLY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-678-0700
Mailing Address - Street 1:91-2139 FORT WEAVER RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3607
Mailing Address - Country:US
Mailing Address - Phone:808-678-0700
Mailing Address - Fax:808-678-0776
Practice Address - Street 1:91-2139 FORT WEAVER RD
Practice Address - Street 2:SUITE 300
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3607
Practice Address - Country:US
Practice Address - Phone:808-678-0700
Practice Address - Fax:808-678-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11807261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000241885Medicaid
HI53920701Medicaid
HI0000241885Medicaid
HIH102367Medicare PIN
HI1790787729Medicare ID - Type Unspecified
HI53920701Medicaid