Healthcare Provider Details

I. General information

NPI: 1114952165
Provider Name (Legal Business Name): WILLIAM M. KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72980 FRED WARING DR. SUITE A
PALM DESERT CA
92260-9339
US

IV. Provider business mailing address

44489 TOWN CENTER WAY STE. D
PALM DESERT CA
92260-2789
US

V. Phone/Fax

Practice location:
  • Phone: 760-776-8001
  • Fax: 760-776-9636
Mailing address:
  • Phone: 760-776-9777
  • Fax: 760-776-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA34125
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberA34125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: