Healthcare Provider Details

I. General information

NPI: 1699032060
Provider Name (Legal Business Name): MATTHEW WILLIAM KELLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 01/24/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 VALLEY VIEW BLVD NW
ROANOKE VA
24012-2040
US

IV. Provider business mailing address

2000 HEALTH PARK DR FL HP2
BRENTWOOD TN
37027-4692
US

V. Phone/Fax

Practice location:
  • Phone: 540-265-4210
  • Fax: 540-265-4219
Mailing address:
  • Phone: 615-373-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203766
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: