Provider Demographics
NPI:1124062443
Name:PHILLIPS, KELLEY L (KELLEY PHILLIPS MD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:KELLEY PHILLIPS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 DENT PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2712
Mailing Address - Country:US
Mailing Address - Phone:202-337-8051
Mailing Address - Fax:202-338-4436
Practice Address - Street 1:875 W MORENO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1731
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD130122084P0800X
CODR.00618942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA185693OtherBCBS VA
NDP00479398OtherRR MEDICARE ND
VA010206758Medicaid
IA0488015Medicaid
DCP00384921OtherRR MEDICARE X
DEP00384921OtherRR MEDICARE S
ND13831Medicaid
MD60484701OtherBCBS MD
MD410407200Medicaid
DCG396-0044OtherBCBS DC
IAP00356148OtherRR MEDICARE IA
VA010206758Medicaid
MD60484701OtherBCBS MD
521740439Medicare PIN
NDN711902Medicare PIN
NDP00479398OtherRR MEDICARE ND
DCP00384921OtherRR MEDICARE X
IA0488015Medicaid
IA117742Medicare PIN
MD744LN376Medicare PIN