Provider Demographics
NPI:1881679553
Name:KELLY, JAMES M (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
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 1:555 W COURT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3664
Mailing Address - Country:US
Mailing Address - Phone:815-932-7246
Mailing Address - Fax:815-932-7307
Practice Address - Street 1:555 W COURT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3664
Practice Address - Country:US
Practice Address - Phone:815-932-7246
Practice Address - Fax:815-932-7307
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065101Medicaid
IL050026565OtherRAILROAD MEDICARE
ILC43215Medicare UPIN
IL036065101Medicaid
ILL25190Medicare ID - Type Unspecified