Provider Demographics
NPI:1972566933
Name:WILLIAM S. KELLY MD PA
Entity Type:Organization
Organization Name:WILLIAM S. KELLY MD PA
Other - Org Name:KERNERSVILLE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANELLE
Authorized Official - Middle Name:V
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-993-1618
Mailing Address - Street 1:420 W MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-2534
Mailing Address - Country:US
Mailing Address - Phone:336-993-1618
Mailing Address - Fax:336-993-5512
Practice Address - Street 1:420 W MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2534
Practice Address - Country:US
Practice Address - Phone:336-993-1618
Practice Address - Fax:336-993-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40743207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC080107394OtherRR MEDICARE
NC890293KMedicaid
NC080107394OtherRR MEDICARE