Healthcare Provider Details

I. General information

NPI: 1922082767
Provider Name (Legal Business Name): WILLIAM M. KELLY M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72980 FRED WARING DR. STE. 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: 760-674-8282
Mailing address:
  • Phone: 760-776-9777
  • Fax: 760-776-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberA34125
License Number StateCA

VIII. Authorized Official

Name: MS. MELONIE STORER
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 951-302-2223