Healthcare Provider Details
I. General information
NPI: 1093940546
Provider Name (Legal Business Name): KELLY E WILLIAMS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 05/27/2009
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:
III. Provider practice location address
5 MORGAN HWY SUITE 4
SCRANTON PA
18508-2641
US
IV. Provider business mailing address
5 MORGAN HWY SUITE 4
SCRANTON PA
18508-2641
US
V. Phone/Fax
- Phone: 570-344-3788
- Fax: 570-969-9280
- Phone: 570-344-3788
- Fax: 570-969-9280
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208100000X |
| Taxonomy | Physical Medicine & Rehabilitation Physician |
| License Number | OT013735 |
| License Number State | PA |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208100000X |
| Taxonomy | Physical Medicine & Rehabilitation Physician |
| License Number | OS017241 |
| License Number State | PA |
| # 3 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208VP0014X |
| Taxonomy | Interventional Pain Medicine Physician |
| License Number | OS017241 |
| License Number State | PA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 102967539-0001 |
| Identifier Type | MEDICAID |
| Identifier State | PA |
| Identifier Issuer | |
| # 2 | |
| Identifier | 1093940546 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | UHC COMMERCIAL & MEDICARE |
| # 3 | |
| Identifier | 4866356 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AETNA |
| # 4 | |
| Identifier | P01389864 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | RR MEDICARE |
| # 5 | |
| Identifier | 30212590 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AMERIHEALTH CARITAS |
| # 6 | |
| Identifier | 6620630 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | CIGNA |
| # 7 | |
| Identifier | 003115409 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | BLUE SHIELD/PREMIER BLUE/MEDICARE ADVANTAGE/FIRST PRIORITY LIFE |
| # 8 | |
| Identifier | 25-1645055 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AETNA BETTER HEALTH |
| # 9 | |
| Identifier | 1093940546 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | GHP |
| # 10 | |
| Identifier | 1093940546 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | HEALTH AMERICA |
| # 11 | |
| Identifier | 833606 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FPH |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
