Provider Demographics
NPI:1659427938
Name:KELLY, MARY THALIA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THALIA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4808 MCMAHON BLVD NW
Mailing Address - Street 2:UNM WESTSIDE CLINIC
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-272-2900
Mailing Address - Fax:505-272-2909
Practice Address - Street 1:INTERNAL MEDICINE
Practice Address - Street 2:MSC 10-5550, 1 UNM
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93-299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF82112Medicare UPIN