Provider Demographics
NPI:1750567244
Name:KELLY K MCCANN MD INC
Entity type:Organization
Organization Name:KELLY K MCCANN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-574-5800
Mailing Address - Street 1:1831 ORANGE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2839
Mailing Address - Country:US
Mailing Address - Phone:949-574-5800
Mailing Address - Fax:949-612-2725
Practice Address - Street 1:1831 ORANGE AVE STE C
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2839
Practice Address - Country:US
Practice Address - Phone:949-574-5800
Practice Address - Fax:949-612-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101853208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORI12587OtherUPIN