=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316566565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTOPHER KELLY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2020
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 FRUIT ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-724-0288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 281 LINCOLN ST STE HM2-212
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-334-8015
-----------------------------------------------------
Fax | 508-334-8235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 1016602
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------