Provider Demographics
NPI:1154368199
Name:KELLEY, SAMUEL K (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:K
Last Name:KELLEY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 VILLAGE SQUARE DR STE B
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7552
Mailing Address - Country:US
Mailing Address - Phone:270-534-5128
Mailing Address - Fax:
Practice Address - Street 1:5050 VILLAGE SQUARE DR STE B
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7552
Practice Address - Country:US
Practice Address - Phone:617-877-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA724272084P0804X
KY596152084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1154368199OtherNPI