Basic Information
| Provider Information | |||||||||
| NPI: | 1548823552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | JUSTIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 SW RAMSEY | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414727000 | ||||||||
| FaxNumber: | 5136866868 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SW RAMSEY | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414727000 | ||||||||
| FaxNumber: | 5136866868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2019 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/04/2019 | ||||||||
| NPIReactivationDate: | 01/03/2020 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD209942 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.