Healthcare Provider Details

I. General information

NPI: 1558627539
Provider Name (Legal Business Name): KEVIN DANIEL KELLEY M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 E MARKET ST
WARREN OH
44483-6637
US

IV. Provider business mailing address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-9399
  • Fax:
Mailing address:
  • Phone: 516-562-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35.132015
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: