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General NPI Number Information
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NPI Number | 1306078225
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Entity Type | Organization
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Legal Business Name | WILLIAM M. KELLY M.D., INC.
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Dates
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Enumeration Date | 08/11/2009
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Last Update Date | 10/18/2013
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Provider Practice Location Address
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Address Line | 72980 FRED WARING DR SUITE A
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City | PALM DESERT
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State | CA
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Zip | 92260-2898
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Country | US
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Telephone | 760-776-8001
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Fax | 760-836-3934
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Provider Business Mailing Address
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Address Line | 44489 TOWN CENTER WAY SUITE D BOX 540
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City | PALM DESERT
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State | CA
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Zip | 92260-2789
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Country | US
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Telephone | 760-776-8001
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Fax | 760-836-3934
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Authorized Official
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Title or Position | CREDENTIALING/CONTRAC ADMINISTRATOR
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Name | TANIA CHANG
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Credential |
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Telephone | 760-776-8001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085D0003X
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Taxonomy Name | Diagnostic Neuroimaging (Radiology) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A34125
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License Number State | CA
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