MEDICARE: WILLIAM R KELLEY MD PROF CORP

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1780804583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM R KELLEY MD PROF CORP

Provider Business Mailing Address
First Line	:	1101 CUMBERLAND XING # 253
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-2356
Country	:	US
Telephone Number	:	928-234-5884
Fax Number	:	928-492-1028

Provider Business Practice Location Address
First Line	:	1510 E WAGON WHEEL LN STE 110
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6698
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM KELLEY
Credential	:	MD
Telephone Number	:	928-234-5884

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	05/07/2019

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