Provider Demographics
NPI:1790787729
Name:KELLY, RUSSELL S (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:91-2139 FORT WEAVER RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3607
Mailing Address - Country:US
Mailing Address - Phone:808-678-0700
Mailing Address - Fax:808-678-0776
Practice Address - Street 1:91-2139 FORT WEAVER RD
Practice Address - Street 2:SUITE 300
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3607
Practice Address - Country:US
Practice Address - Phone:808-678-0700
Practice Address - Fax:808-678-0776
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
HI11807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000241885Medicaid
HI539207Medicaid
HI539207Medicaid
HIH102367Medicare PIN