Provider Demographics
NPI:1316125131
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-776-8001
Mailing Address - Street 1:72980 FRED WARING DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-9339
Mailing Address - Country:US
Mailing Address - Phone:760-776-9636
Mailing Address - Fax:
Practice Address - Street 1:44489 TOWN CENTER WAY
Practice Address - Street 2:SUITE D BOX 540
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2723
Practice Address - Country:US
Practice Address - Phone:760-346-2257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
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