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General NPI Number Information
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NPI Number | 1467633651
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Entity Type | Organization
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Legal Business Name | RICHARD A KELLY MD, PA
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Dates
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Enumeration Date | 11/16/2007
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Last Update Date | 11/16/2007
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Provider Practice Location Address
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Address Line | 210 GOODMAN RD E
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9520
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Country | US
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Telephone | 662-349-2251
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Fax |
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Provider Business Mailing Address
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Address Line | 210 GOODMAN RD E
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9520
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Country | US
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Telephone | 662-349-2251
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD ALLEN KELLY
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Credential | MD
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Telephone | 662-349-2251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MS11375
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License Number State | MS
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