Basic Information
| Provider Information | |||||||||
| NPI: | 1730170374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | SHERWOOD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369931618 | ||||||||
| FaxNumber: | 3369935512 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369931618 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 26282 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207Q00000X | 26282 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26282 | 01 | NC | STATE LICENSE | OTHER | 8948272 | 05 | NC | MEDICAID | 080107394 | 01 | NC | RR MEDICARE | OTHER |