Healthcare Provider Details

I. General information

NPI: 1306089230
Provider Name (Legal Business Name): BRIAN THOMAS KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16929 FRANCES ST STE 101
OMAHA NE
68130
US

IV. Provider business mailing address

555 N 30TH ST
OMAHA NE
68131-2136
US

V. Phone/Fax

Practice location:
  • Phone: 402-758-5125
  • Fax: 531-255-0001
Mailing address:
  • Phone: 531-355-6540
  • Fax: 531-355-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59455
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number55878
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55878
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number59455
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: