Provider Demographics
NPI:1841397445
Name:KELLY, ROBERT R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 WINTER ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3919
Mailing Address - Country:US
Mailing Address - Phone:888-828-3198
Mailing Address - Fax:
Practice Address - Street 1:665 WINTER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3919
Practice Address - Country:US
Practice Address - Phone:503-561-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10660207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8443129Medicaid
A052OtherCHAMPUS
CAXPY049930Medicaid
OR116863Medicaid
C91106OtherPROVIDENCE
C91106OtherGROUP HEALTH
116863OtherMARION POLK CHP
WA185702OtherL & I
WA185702OtherL & I
116863OtherMARION POLK CHP