Provider Demographics
NPI:1932107208
Name:KELLY, JODY L (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:L
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 1:2901 N. KNOXVILLE AVE.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603
Mailing Address - Country:US
Mailing Address - Phone:309-688-7010
Mailing Address - Fax:309-688-7044
Practice Address - Street 1:2901 N. KNOXVILLE AVE.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-688-7010
Practice Address - Fax:309-688-7044
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2011-12-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IL036102228207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102228Medicaid
IL036102228Medicaid
IL209281Medicare ID - Type Unspecified