Provider Demographics
NPI:1831270073
Name:PHELPS, KELLY C (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:PHELPS
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 1:203 S DAISY ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-0000
Mailing Address - Country:US
Mailing Address - Phone:208-756-5600
Mailing Address - Fax:208-756-4169
Practice Address - Street 1:203 S DAISY ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-0000
Practice Address - Country:US
Practice Address - Phone:208-756-5600
Practice Address - Fax:208-756-4169
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5808207P00000X
IDM5808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004220800Medicaid
ID004220800Medicaid
A29630Medicare UPIN