Provider Demographics
NPI:1669589677
Name:KELLEY, RALPH (DO)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1616
Mailing Address - Country:US
Mailing Address - Phone:573-379-3777
Mailing Address - Fax:
Practice Address - Street 1:314 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1616
Practice Address - Country:US
Practice Address - Phone:573-379-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31361207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241143213Medicaid
MO000095621Medicare ID - Type Unspecified
MO241143213Medicaid