Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | MD2011-0248 | NM |
N | 111NI0900X | Internist | MD2011-0248 | NM |
Y | 207RG0300X | Geriatric Medicine | MD2011-0248 | NM |
NPI | 1043349608 |
---|---|
Provider Name | Jeremiah F Kelly |
First Address | Albuquerque, NM 87131-0001 |
Second Address | Albuquerque, NM 87131-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2007 |
Last Update Date | 10/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A47268 | (02) | IL |