Basic Information
| Provider Information | |||||||||
| NPI: | 1104861343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 W MAIN ST | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177380660 | ||||||||
| FaxNumber: | 7177380658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1635 W MAIN ST | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177380660 | ||||||||
| FaxNumber: | 7177380658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD428418 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107754 S1QF | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 1429961 | 01 | PA | AETNA HMO | OTHER | 50061893 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 50060203 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1874597 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | P008054 | 01 | PA | GATEWAY HEALTH PLAN | OTHER | 7276819 | 01 | PA | AETNA NON-HMO | OTHER | I54742 | 01 | PA | HEALTH ASSURANCE | OTHER | 50061968 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 50065832 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1016458260001 | 05 | PA | MEDICAID |