Healthcare Provider Details

I. General information

NPI: 1972566933
Provider Name (Legal Business Name): WILLIAM S. KELLY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MOUNTAIN ST
KERNERSVILLE NC
27284-2534
US

IV. Provider business mailing address

420 W MOUNTAIN ST
KERNERSVILLE NC
27284-2534
US

V. Phone/Fax

Practice location:
  • Phone: 336-993-1618
  • Fax: 336-993-5512
Mailing address:
  • Phone: 336-993-1618
  • Fax: 336-993-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number40743
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40743
License Number StateNC

VIII. Authorized Official

Name: MS. JOANELLE V KELLY
Title or Position: OFFICE MANAGER
Credential:
Phone: 336-993-1618