Healthcare Provider Details

I. General information

NPI: 1467495226
Provider Name (Legal Business Name): KELLY MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13921 N MERIDIAN AVE STE 100
OKLAHOMA CITY OK
73134-1106
US

IV. Provider business mailing address

PO BOX 268938
OKLAHOMA CITY OK
73126-8938
US

V. Phone/Fax

Practice location:
  • Phone: 405-752-9600
  • Fax: 405-752-9650
Mailing address:
  • Phone: 405-752-9600
  • Fax: 405-752-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN BLAKE KELLY
Title or Position: DOCTOR
Credential: MD
Phone: 405-752-9600