Provider Demographics
NPI:1689933467
Name:JEFFERY S KELLEY MD
Entity Type:Organization
Organization Name:JEFFERY S KELLEY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-675-4546
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-0010
Mailing Address - Country:US
Mailing Address - Phone:850-675-4546
Mailing Address - Fax:850-675-4548
Practice Address - Street 1:14088 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1036
Practice Address - Country:US
Practice Address - Phone:850-675-4546
Practice Address - Fax:850-675-4548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009952450OtherALACAID
7032394OtherAETNA
59037346OtherBLUE CROSS AND BLUE SHIELD OF ALABAMA
591032244OtherCHAMPVA
P00017883OtherRAILROAD MEDICARE
FL261059100Medicaid
4071564OtherCIGNA
A611OtherWELLCARE
05101OtherBLUE CROSS AND BLUE SHIELD OF FLORIDA
1203400OtherCOVENTRY
2239990OtherUNITED HEALTHCARE
591032244OtherTRICARE
FLH38550Medicare UPIN
FLE5615Medicare PIN