Healthcare Provider Details

I. General information

NPI: 1427016633
Provider Name (Legal Business Name): MARK KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SPRING ST
LACONIA NH
03246-3113
US

IV. Provider business mailing address

85 SPRING ST
LACONIA NH
03246-3113
US

V. Phone/Fax

Practice location:
  • Phone: 603-524-7402
  • Fax:
Mailing address:
  • Phone: 603-524-7402
  • Fax: 603-227-7596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number11416
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number11416
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number11416
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: