Basic Information
| Provider Information | |||||||||
| NPI: | 1427016633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035247402 | ||||||||
| FaxNumber: | 6032277596 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035247402 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11416 | NH | N | Other Service Providers | Specialist | 207YX0602X | 11416 | NH | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207Y00000X | 11416 | NH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 30201594 | 05 | NH | MEDICAID | 3077628 | 05 | NH | MEDICAID |