Provider Demographics
NPI:1013103860
Name:DR JAMES R KELLY M D P C
Entity Type:Organization
Organization Name:DR JAMES R KELLY M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-222-5555
Mailing Address - Street 1:901 STEWART AVE
Mailing Address - Street 2:SUTIE 255
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4893
Mailing Address - Country:US
Mailing Address - Phone:516-222-5555
Mailing Address - Fax:
Practice Address - Street 1:901 STEWART AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4893
Practice Address - Country:US
Practice Address - Phone:516-222-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197045207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWET551Medicare PIN