Healthcare Provider Details

I. General information

NPI: 1760850853
Provider Name (Legal Business Name): CHAD KELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987400 NEBRASKA MEDICAL CTR
OMAHA NE
68198-7400
US

IV. Provider business mailing address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-7000
  • Fax: 402-559-7592
Mailing address:
  • Phone: 402-559-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1943
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: