Basic Information
| Provider Information | |||||||||
| NPI: | 1548297930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 FRANKLIN ST. | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST. | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 035359 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 035359 | 01 | CT | CONNECTICARE | OTHER | P407727 | 01 | CT | OXFORD HEALTH PLANS | OTHER | 10-86502 | 01 | CT | UHC | OTHER | 4369921 | 01 | CT | AETNA HEALTH PLANS | OTHER | 01035359 | 01 | CT | CIGNA HEALTH PLANS | OTHER | 0R03179 | 01 | CT | HEALTH NET OF NORTHEAST | OTHER | 206706 | 01 | CT | WELLCARE | OTHER | 604583 | 01 | CT | UNITED HEALTHCARE | OTHER | P00025411 | 01 | CT | RR MEDICARE | OTHER | 010035359CT01 | 01 | CO | ANTHEM BC & BS | OTHER | 873719 | 01 | CT | USA | OTHER | 001353599 | 05 | CT | MEDICAID |