MEDICARE: RICHARD DWAIN KELLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	L6457	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376565820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD DWAIN KELLEY MD

Provider Business Mailing Address
First Line	:	3401 ALDWYCHE DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-5913
Country	:	US
Telephone Number	:	512-569-4457
Fax Number	:

Provider Business Practice Location Address
First Line	:	13435 N HWY 183 STE 311
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-3258
Country	:	US
Telephone Number	:	512-614-1200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	04/24/2017

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