Healthcare Provider Details

I. General information

NPI: 1578859872
Provider Name (Legal Business Name): KELLY MCDONOUGH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

IV. Provider business mailing address

101 DUDLEY ST PHO OFFICE
PROVIDENCE RI
02905-2401
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-1122
  • Fax: 401-453-7597
Mailing address:
  • Phone: 401-274-1122
  • Fax: 401-453-7597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLP02223
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number258025
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: