Provider Demographics
NPI:1811272388
Name:ERIC KELLEY, M.D.,S.C.
Entity type:Organization
Organization Name:ERIC KELLEY, M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-344-7171
Mailing Address - Street 1:2215 SOUTH 17TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3908
Mailing Address - Country:US
Mailing Address - Phone:708-344-7171
Mailing Address - Fax:708-344-0319
Practice Address - Street 1:2215 SOUTH 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3908
Practice Address - Country:US
Practice Address - Phone:708-344-7171
Practice Address - Fax:708-344-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057671Medicaid
IL036057671Medicaid