Provider Demographics
NPI:1700863685
Name:KELLEY, SCOTT W (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:12805 W BURLEIGH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3111
Practice Address - Country:US
Practice Address - Phone:262-797-6434
Practice Address - Fax:262-797-6429
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI36968207ZD0900X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32649200Medicaid
IA0540955Medicaid
WI132700009Medicare PIN
WI162450010Medicare PIN
WI017600024Medicare PIN
WI32649200Medicaid
WI682300021Medicare PIN
IA0540955Medicaid
WI222950009Medicare PIN