Basic Information
| Provider Information | |||||||||
| NPI: | 1659427938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | THALIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLY | ||||||||
| OtherFirstName: | MOLLY | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4808 MCMAHON BLVD NW | ||||||||
| Address2: | UNM WESTSIDE CLINIC | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722900 | ||||||||
| FaxNumber: | 5052722909 | ||||||||
| Practice Location | |||||||||
| Address1: | INTERNAL MEDICINE | ||||||||
| Address2: | MSC 10-5550, 1 UNM | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722147 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 93-299 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.