Provider Demographics
NPI:1720179583
Name:KELLY, EILEEN A (MD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-534-3278
Mailing Address - Fax:847-535-8590
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-534-3278
Practice Address - Fax:847-535-8590
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109019207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G50991Medicare UPIN