Healthcare Provider Details

I. General information

NPI: 1932107208
Provider Name (Legal Business Name): JODY L KELLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

2901 N. KNOXVILLE AVE.
PEORIA IL
61603
US

IV. Provider business mailing address

2901 N. KNOXVILLE AVE.
PEORIA IL
61603
US

V. Phone/Fax

Practice location:
  • Phone: 309-688-7010
  • Fax: 309-688-7044
Mailing address:
  • Phone: 309-688-7010
  • Fax: 309-688-7044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036102228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: