Healthcare Provider Details

I. General information

NPI: 1669589677
Provider Name (Legal Business Name): RALPH KELLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E MAIN ST
PORTAGEVILLE MO
63873-1616
US

IV. Provider business mailing address

314 E MAIN ST
PORTAGEVILLE MO
63873-1616
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-3777
  • Fax:
Mailing address:
  • Phone: 573-379-3777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number31361
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: