MEDICARE: KIMBERLY RAE 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	207N00000X	Dermatology Physician	5817	ND
2	207N00000X	Dermatology Physician	33100	MN

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
2	0300403	OTHER		MEDICA
3	25535	OTHER	ND	BLUE SHIELD
4	511R8KE	OTHER	MN	BLUE SHIELD
5	772090400	OTHER	MN	MEDICAL ASSISTANCE
6	HP17495	OTHER		HEALTHPARTNERS

General Provider Information

NPI Number	:	1245223023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY RAE KELLY MD

Provider Business Mailing Address
First Line	:	PO BOX 6001
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58108-6001
Country	:	US
Telephone Number	:	701-364-3300
Fax Number	:	701-364-8906

Provider Business Practice Location Address
First Line	:	1702 UNIVERSITY DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58103-4940
Country	:	US
Telephone Number	:	701-364-3300
Fax Number	:	701-364-8906

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

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	08/25/2011

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Directions to “ KIMBERLY RAE KELLY MD” Practice Location

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