Healthcare Provider Details

I. General information

NPI: 1114943990
Provider Name (Legal Business Name): ROGER EVERETT KELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

131 S. ROBERTSON STREET, STE. 1300 CENTER FOR CLINICAL NEUROSCIENCES
NEW ORLEANS LA
70112
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax:
Mailing address:
  • Phone: 504-988-1133
  • Fax: 504-988-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number013686
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD.013686
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: