Basic Information
| Provider Information | |||||||||
| NPI: | 1669589677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 314 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733793777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 314 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733793777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 31361 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 241143213 | 05 | MO | MEDICAID |