Provider Demographics
NPI:1871501353
Name:KELLEY, KATHLEEN ANN (MD, RPH)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:ANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SOUTHWICK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1650
Mailing Address - Country:US
Mailing Address - Phone:716-662-7242
Mailing Address - Fax:
Practice Address - Street 1:2943 SENECA STREET
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1950
Practice Address - Country:US
Practice Address - Phone:716-825-3601
Practice Address - Fax:716-825-2850
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0003513183500000X
NY164393-1208600000X
WV21979208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1706438OtherINDEPENDENT HEALTH
040426000362OtherFEDELES CARE
00010089001OtherSENIOR DEVICE UNIVERA
000527022003OtherBLUE CROSS BLUE SHIELD
NY01209521Medicaid
0151643931OtherWORKMANS COMP
NY01209521Medicaid
NY11321AMedicare PIN