Provider Demographics
NPI:1649271883
Name:KELLY, PETER J (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1215
Mailing Address - Country:US
Mailing Address - Phone:413-283-3511
Mailing Address - Fax:413-283-5396
Practice Address - Street 1:1504 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1215
Practice Address - Country:US
Practice Address - Phone:413-283-3511
Practice Address - Fax:413-283-5396
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41270207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
042744585OtherCOSTCARE PPO
042744585OtherGEHA PPO
042744585OtherCHOICECARE
350270OtherCMHC
S030683OtherCHAMPUS
042744585OtherHMC PPO
0598171-003OtherCIGNA
0000000020721OtherHEALTHNET
0025915OtherAETNA
042744585OtherHCVM
1582315OtherFIRST HEALTH
H15034OtherBCBS
150714OtherHARVARD PILGRIM
744585OtherCONNECTICARE
MA1270OtherEYEMED
042744585OtherTAX ID
MA9739319Medicaid
PAL: 39699OtherDAVIS VISION
150714OtherHARVARD PILGRIM
1582315OtherFIRST HEALTH
H15034Medicare ID - Type Unspecified