Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 2006017916 | MO |
NPI | 1053377333 |
---|---|
Provider Name | Dr. James Kelly |
First Address | Saint Louis, MO 63118-3930 |
Second Address | Saint Louis, MO 63118-3930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 03/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G27401 | (02) |