Provider Demographics
NPI:1598953739
Name:RAYMOND J KELLY, M.D. INC
Entity Type:Organization
Organization Name:RAYMOND J KELLY, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-344-2561
Mailing Address - Street 1:100 S ELLSWORTH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3939
Mailing Address - Country:US
Mailing Address - Phone:650-344-2561
Mailing Address - Fax:650-344-2563
Practice Address - Street 1:100 S ELLSWORTH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3939
Practice Address - Country:US
Practice Address - Phone:650-344-2561
Practice Address - Fax:650-344-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 023921207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356409239OtherTYPE 1 NPI
CAG 023921OtherLISCENSE
CAA42104Medicare UPIN
CA1356409239OtherTYPE 1 NPI