Provider Demographics
NPI:1619944113
Name:KELLY, GEORGE TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:TIMOTHY
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 1:7200 CATHEDRAL ROCK DR
Mailing Address - Street 2:#110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0438
Mailing Address - Country:US
Mailing Address - Phone:702-341-5444
Mailing Address - Fax:702-341-5445
Practice Address - Street 1:7200 CATHEDRAL ROCK DR
Practice Address - Street 2:#110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0438
Practice Address - Country:US
Practice Address - Phone:702-341-5444
Practice Address - Fax:702-341-5445
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMD5260174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV88-0388402OtherTAX ID #
NVE80753Medicare UPIN
NVVMD5260Medicare PIN