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1013995471

NPI Code Detail

MEDICARE: EDWARD LESLIE KELLY MD

MEDICARE: EDWARD LESLIE KELLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	26951	NE
2	2084F0202X	Forensic Psychiatry Physician	42929	MN
3	2084F0202X	Forensic Psychiatry Physician	MD00040860	WA
4	2084P0800X	Psychiatry Physician	26951	NE
5	2084P0800X	Psychiatry Physician	MD00040860	WA
6	2084P0804X	Child & Adolescent Psychiatry Physician	MD00040860	WA
7	2084P0805X	Geriatric Psychiatry Physician	MD00040860	WA
8	2084F0202X	Forensic Psychiatry Physician	10382404-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013995471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD LESLIE KELLY MD

Provider Business Mailing Address
First Line	:	PO BOX 270
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84603-0270
Country	:	US
Telephone Number	:	801-344-4400
Fax Number	:	801-344-4225

Provider Business Practice Location Address
First Line	:	1300 E CENTER ST
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84606-3554
Country	:	US
Telephone Number	:	801-344-4400
Fax Number	:	801-344-4225

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	03/24/2025

Similar Medicare Providers

1811978620 — STATE OF UTAH
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4400
Practice Fax: 801-344-4225

1205812450 — MR. JEREMY LEE CHRISTENSEN LCSW
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4400
Practice Fax:

1114905965 — DR. JOHN B BENCH M.D.
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4400
Practice Fax: 801-344-4225

1386624625 — MR. DEREK PAUL DAVIS LCSW
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4215
Practice Fax:

1740250372 — DR. RICHARD WAYNE MICKELSEN M.D.
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4215
Practice Fax: 801-344-4225

1265485593 — MR. ROBERT S. SPENCER APRN
Practice Location Address:

1300 E CENTER ST
PROVO, UT
84606-3554

Practice Phone: 801-344-4400
Practice Fax:

Directions to “ EDWARD LESLIE KELLY MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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