Basic Information
| Provider Information | |||||||||
| NPI: | 1659324473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | NO 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 3037616322 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E HAMPDEN AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 3037616322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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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 | 2085R0202X | 42731 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1659324473 | 05 | WY | MEDICAID | 1659324473 | 05 | NV | MEDICAID | 200094308 | 05 | MO | MEDICAID | 0257149 | 01 | WA | DEPT OF LABOR | OTHER | 104705317 | 05 | MI | MEDICAID | 1650324473/7729360 | 05 | SD | MEDICAID | 39230864 | 05 | NM | MEDICAID | P00760021 | 01 | CO | RR MCR MIC | OTHER | 1659324473 | 05 | UT | MEDICAID | XPY202415 | 05 | CA | MEDICAID | 1659324473 | 05 | MT | MEDICAID | P00141622 | 01 | CO | RR RIA MEDICARE | OTHER | 10025709000 | 05 | NE | MEDICAID | 1659324473 | 05 | TX | MEDICAID | 200418360A | 05 | KS | MEDICAID | 99111450 | 05 | WI | MEDICAID | 261632 | 05 | AZ | MEDICAID | 38324041 | 05 | CO | MEDICAID | 84-059792913 | 05 | NE | MEDICAID |