Provider Demographics
NPI:1528068178
Name:KELLY, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3838
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:3815 E BELL RD
Practice Address - Street 2:SUITE 4100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2122
Practice Address - Country:US
Practice Address - Phone:602-494-5040
Practice Address - Fax:602-494-4020
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110222435OtherRAILROAD MEDICARE
AZ054750Medicaid
AZZ155970Medicare UPIN
110222435OtherRAILROAD MEDICARE
AZ054750Medicaid