MEDICARE: RUSSELL S 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	207R00000X	Internal Medicine Physician	11807	HI

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790787729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL S KELLY MD

Provider Business Mailing Address
First Line	:	91-2139 FORT WEAVER RD
Second Line	:	SUITE 300
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3607
Country	:	US
Telephone Number	:	808-678-0700
Fax Number	:	808-678-0776

Provider Business Practice Location Address
First Line	:	91-2139 FORT WEAVER RD
Second Line	:	SUITE 300
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3607
Country	:	US
Telephone Number	:	808-678-0700
Fax Number	:	808-678-0776

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	02/06/2008

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Directions to “ RUSSELL S KELLY MD” Practice Location

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