Provider Demographics
NPI:1982600979
Name:KELLEY, KEVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4689 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2379
Mailing Address - Country:US
Mailing Address - Phone:330-649-9400
Mailing Address - Fax:330-649-8059
Practice Address - Street 1:4689 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2379
Practice Address - Country:US
Practice Address - Phone:330-649-9400
Practice Address - Fax:330-649-8059
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHKE4069601207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2313740Medicaid
OHH55786Medicare UPIN
OHKE4069601Medicare ID - Type Unspecified