Provider Demographics
NPI:1487614020
Name:KELLY, BENSON J (MD)
Entity type:Individual
Prefix:DR
First Name:BENSON
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:AKWESASNE
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:AKWESASNE
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B81749Medicare UPIN