Provider Demographics
NPI:1134283864
Name:JOHN PAUL KELLY
Entity type:Organization
Organization Name:JOHN PAUL KELLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-883-5955
Mailing Address - Street 1:PO BOX 29872
Mailing Address - Street 2:DEPT 29
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9872
Mailing Address - Country:US
Mailing Address - Phone:775-883-5955
Mailing Address - Fax:775-883-5992
Practice Address - Street 1:1535 MEDICAL PARKWAY
Practice Address - Street 2:SUITE B
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703
Practice Address - Country:US
Practice Address - Phone:775-883-5955
Practice Address - Fax:775-883-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1296207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1962593731OtherDR MEADORS INDIV NPI
NV1477512234OtherDR KELLY INDIV NPI
NV1649340738OtherKARA COLE APN MS INDI NPI
NV1134283864OtherMDCR GROUP NPI
NVCC1356OtherDR KELLY BLUE SHIELD
NVH34598Medicare UPIN
NV39266Medicare ID - Type UnspecifiedKARA COLE MDCR PROV ID
NVE37351Medicare UPIN
NVCC1356OtherDR KELLY BLUE SHIELD