Healthcare Provider Details

I. General information

NPI: 1033233192
Provider Name (Legal Business Name): BRENDAN PATRICK KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

22 DEL PRADO ST
LAKE OSWEGO OR
97035-1312
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8500
  • Fax: 541-222-6435
Mailing address:
  • Phone: 503-305-6577
  • Fax: 503-305-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD60095370
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD29308
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301080000
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: