Provider Demographics
NPI:1881727212
Name:KELLY, WILLIAM FERRIS JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FERRIS
Last Name:KELLY
Suffix:JR
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 1:107 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-9668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6338
Practice Address - Country:US
Practice Address - Phone:910-577-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0034643174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0760COtherBLUE CROSS GROUP
NC6907604Medicaid
NC562014989001OtherTRICARE GROUP
NC8948216Medicaid
NC48216OtherBLUE SHIELD NC
NC48216OtherBLUE SHIELD NC
NCF26948Medicare UPIN
NC0760COtherBLUE CROSS GROUP