Basic Information
| Provider Information | |||||||||
| NPI: | 1093126427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 SIGNAL TREE DR STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TIMNATH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805474908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702377415 | ||||||||
| FaxNumber: | 9702377420 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 SIGNAL TREE DR STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TIMNATH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805474908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702377415 | ||||||||
| FaxNumber: | 9702377420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TL0005132 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0055887 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9000175262 | 05 | CO | MEDICAID |