MEDICARE: SAMUEL K KELLEY M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	59615	KY
2	2084P0804X	Child & Adolescent Psychiatry Physician	72427	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1154368199	OTHER	MA	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154368199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL K KELLEY M.D.

Provider Business Mailing Address
First Line	:	5050 VILLAGE SQUARE DR STE B
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-7552
Country	:	US
Telephone Number	:	270-534-5128
Fax Number	:

Provider Business Practice Location Address
First Line	:	2327 NEW HOLT RD
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-7404
Country	:	US
Telephone Number	:	270-534-5128
Fax Number	:	270-477-0007

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	11/03/2025

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