Provider Demographics
NPI:1629151949
Name:KELLY, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
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 1:357 GENESEE STREET
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421
Mailing Address - Country:US
Mailing Address - Phone:315-363-8800
Mailing Address - Fax:315-363-0103
Practice Address - Street 1:357 GENESEE STREET
Practice Address - Street 2:ONEIDA SURGICAL GROUP PC
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421
Practice Address - Country:US
Practice Address - Phone:315-363-8800
Practice Address - Fax:315-363-0103
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181918208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
025001OtherMVP
00040192301OtherUNIVERA
00911284001OtherBS OF NORTHEASTERN NY
0100576OtherGHI
22160OtherHEALTHSOURCE HMO NY
5897089OtherAETNA US HEALTHCARE
NY01192492Medicaid
00911284001OtherBS OF NORTHEASTERN NY
E87604Medicare UPIN