Provider Demographics
NPI:1780804583
Name:WILLIAM R KELLEY MD PROF CORP
Entity type:Organization
Organization Name:WILLIAM R KELLEY MD PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-234-5884
Mailing Address - Street 1:1101 CUMBERLAND XING # 253
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2356
Mailing Address - Country:US
Mailing Address - Phone:928-234-5884
Mailing Address - Fax:928-492-1028
Practice Address - Street 1:1510 E WAGON WHEEL LN STE 110
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6698
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32517ZMedicare PIN
AZE11189Medicare UPIN
AZZ101711Medicare PIN