Provider Demographics
NPI:1427079961
Name:KELLY, KAY PONTIUS (MD)
Entity type:Individual
Prefix:MRS
First Name:KAY
Middle Name:PONTIUS
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25451 MENOMINI CT
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189
Mailing Address - Country:US
Mailing Address - Phone:630-254-5352
Mailing Address - Fax:630-810-1037
Practice Address - Street 1:25451 MENOMINI CT
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189
Practice Address - Country:US
Practice Address - Phone:630-254-5352
Practice Address - Fax:630-810-1037
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056877208000000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-056877Medicaid