Healthcare Provider Details

I. General information

NPI: 1366608945
Provider Name (Legal Business Name): KENNETH M KELLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST PSSB 2100
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

2219 H ST APT. #2
SACRAMENTO CA
95816-4045
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5010
  • Fax: 916-734-7950
Mailing address:
  • Phone: 312-208-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA108350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: