Provider Demographics
NPI:1306078225
Name:WILLIAM M. KELLY M.D., INC.
Entity type:Organization
Organization Name:WILLIAM M. KELLY M.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CONTRAC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-776-8001
Mailing Address - Street 1:44489 TOWN CENTER WAY
Mailing Address - Street 2:SUITE D BOX 540
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-2789
Mailing Address - Country:US
Mailing Address - Phone:760-776-8001
Mailing Address - Fax:760-836-3934
Practice Address - Street 1:72980 FRED WARING DR
Practice Address - Street 2:SUITE A
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2898
Practice Address - Country:US
Practice Address - Phone:760-776-8001
Practice Address - Fax:760-836-3934
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM M. KELLY M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-11
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085D0003X
CAA34125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341250Medicaid
CAZZZ22856ZMedicare PIN
CAA27387Medicare UPIN
CA00A341250Medicaid
CAZZZ22857ZMedicare PIN
CAZZZ26694ZMedicare PIN
CAZZZ02829ZMedicare PIN
ZZZ22856ZMedicare PIN