=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184804999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JON P. KELLY, M.D., A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 11/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 N ELM ST SUITE 105
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-743-0100
-----------------------------------------------------
Fax | 760-743-1414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 N ELM ST SUITE 105
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-743-0100
-----------------------------------------------------
Fax | 760-743-1414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | JON PEMBROKE KELLY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-743-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A45013
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------