Provider Demographics
NPI:1366608945
Name:KELLEY, KENNETH M (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2219 H ST
Mailing Address - Street 2:APT. #2
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4045
Mailing Address - Country:US
Mailing Address - Phone:312-208-5090
Mailing Address - Fax:
Practice Address - Street 1:4150 V ST
Practice Address - Street 2:PSSB 2100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-734-5010
Practice Address - Fax:916-734-7950
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL390200000X
CAA108350207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program