Provider Demographics
NPI:1316920895
Name:KELLY, ANDREW P (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
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:PO BOX 5686
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5686
Mailing Address - Country:US
Mailing Address - Phone:888-598-8819
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:555 E HARDY STREET
Practice Address - Street 2:CENTINELA HOSPITAL MEDICAL CENTER
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-673-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG664982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G664980OtherBLUE SHIELD
CA00G664980Medicaid
00G664980E02OtherCALOPTIMA
050739CF85471OtherTRAILBLAZER
P00225785OtherRAILROAD MEDICARE
P00225785OtherRAILROAD MEDICARE
00G664980E02OtherCALOPTIMA