Provider Demographics
NPI:1699278267
Name:PETER R. KELLY M.D. INC
Entity type:Organization
Organization Name:PETER R. KELLY M.D. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:LONI
Authorized Official - Last Name:SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-435-0186
Mailing Address - Street 1:1224 10TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3420
Mailing Address - Country:US
Mailing Address - Phone:619-435-0186
Mailing Address - Fax:619-435-0594
Practice Address - Street 1:1224 10TH ST STE 205
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3420
Practice Address - Country:US
Practice Address - Phone:619-435-0186
Practice Address - Fax:619-435-0594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETER R. KELLY M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty