Provider Demographics
NPI:1245223023
Name:KELLY, KIMBERLY RAE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5817207N00000X
MN33100207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16323Medicaid
0300403OtherMEDICA
ND25535OtherBLUE SHIELD
MN511R8KEOtherBLUE SHIELD
MN772090400OtherMEDICAL ASSISTANCE
HP17495OtherHEALTHPARTNERS
ND25535OtherBLUE SHIELD
0300403OtherMEDICA