Provider Demographics
NPI:1710901418
Name:KELLY, TAMMAS F (MD)
Entity Type:Individual
Prefix:
First Name:TAMMAS
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 REMINGTON ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3074
Mailing Address - Country:US
Mailing Address - Phone:970-484-5625
Mailing Address - Fax:970-493-5131
Practice Address - Street 1:503 REMINGTON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3074
Practice Address - Country:US
Practice Address - Phone:970-484-5625
Practice Address - Fax:970-493-5131
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO303972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO058853OtherVALUE OPTIONS
CO11759852Medicaid
COE67150Medicare UPIN
CO11759852Medicaid