Healthcare Provider Details

I. General information

NPI: 1811985112
Provider Name (Legal Business Name): BRIAN D. KELLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

777 AVENUE H
POWELL WY
82435-2260
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-2267
  • Fax: 307-754-7217
Mailing address:
  • Phone: 307-754-2267
  • Fax: 307-754-7217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS0005851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: