Provider Demographics
NPI:1700868338
Name:WILLIAM M. KELLY M.D., INC.
Entity Type:Organization
Organization Name:WILLIAM M. KELLY M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STORER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-302-2223
Mailing Address - Street 1:44489 TOWN CENTER WAY
Mailing Address - Street 2:STE. D
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-2789
Mailing Address - Country:US
Mailing Address - Phone:760-776-9777
Mailing Address - Fax:760-776-4999
Practice Address - Street 1:40700 CALIFORNIA OAKS RD
Practice Address - Street 2:STE 103
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-894-4418
Practice Address - Fax:951-894-4419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM M. KELLY M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-18
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085D0003X
CAA341252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA341253Medicaid
CAA341253Medicaid
ZZZ22B56ZMedicare PIN
A27387Medicare UPIN