Provider Demographics
NPI:1366428302
Name:JAMES, KELLY MICHAEL
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHAEL
Last Name:JAMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19101 E VALLEY VIEW PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6904
Mailing Address - Country:US
Mailing Address - Phone:816-254-9292
Mailing Address - Fax:816-795-8996
Practice Address - Street 1:19101 E VALLEY VIEW PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6904
Practice Address - Country:US
Practice Address - Phone:816-254-9292
Practice Address - Fax:816-795-8996
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD104164208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19543010OtherBLUE CROSS-BLUE SHIELD
MO206857203Medicaid
MO19543010OtherBLUE CROSS-BLUE SHIELD
MO2145471Medicare ID - Type Unspecified