Provider Demographics
NPI:1639602493
Name:KELLY MILTON, PLLC
Entity type:Organization
Organization Name:KELLY MILTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-752-1304
Mailing Address - Street 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:BUILDING D
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3709
Mailing Address - Country:US
Mailing Address - Phone:602-843-3811
Mailing Address - Fax:
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:BUILDING D
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-843-3811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-09
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ485742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ921314Medicaid