Basic Information
| Provider Information | |||||||||
| NPI: | 1093805087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172691940 | ||||||||
| FaxNumber: | 4172691948 | ||||||||
| Practice Location | |||||||||
| Address1: | 941 E HUBBLE DR | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657062538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172691940 | ||||||||
| FaxNumber: | 4172691948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 105766 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107908 | 01 | MO | BCMO | OTHER | 208663419 | 05 | MO | MEDICAID |