Healthcare Provider Details

I. General information

NPI: 1023071016
Provider Name (Legal Business Name): KELLY LEAF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST EMERGENCY DEPARTMENT
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

24800 SE STARK ST EMERGENCY DEPARTMENT
GRESHAM OR
97030-3378
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1122
  • Fax:
Mailing address:
  • Phone: 503-674-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD22901
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier202438
Identifier TypeOTHER
Identifier State
Identifier IssuerWA L&I
# 2
Identifier8370835
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier287166
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 4
Identifier858543006
Identifier TypeOTHER
Identifier State
Identifier IssuerREGENCE BC/BS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: