Provider Demographics
NPI:1801306998
Name:KELLY, ORIN A SR
Entity type:Individual
Prefix:
First Name:ORIN
Middle Name:A
Last Name:KELLY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5204
Mailing Address - Country:US
Mailing Address - Phone:414-759-2276
Mailing Address - Fax:
Practice Address - Street 1:4856 N 40TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5204
Practice Address - Country:US
Practice Address - Phone:414-759-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIK4006417318200343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)