Provider Demographics
NPI:1801990478
Name:KELLY, BRIAN WILBUR (MD)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILBUR
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 SE OAK ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4147
Mailing Address - Country:US
Mailing Address - Phone:503-640-5950
Mailing Address - Fax:503-648-3140
Practice Address - Street 1:545 SE OAK ST
Practice Address - Street 2:SUITE F
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4147
Practice Address - Country:US
Practice Address - Phone:503-640-5950
Practice Address - Fax:503-648-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10756207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227538Medicaid
ORC9123100001OtherPROVIDENCE
ORDG4207OtherRAILROAD MEDICARE GROUP #
OR003293001OtherBCBS
ORR0000WCJCBMedicare ID - Type Unspecified
ORC91231Medicare UPIN
OR003293001OtherBCBS
ORC9123100001OtherPROVIDENCE