Provider Demographics
NPI:1548823552
Name:KELLY, NATHANIEL JUSTIN (MD)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:JUSTIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SW RAMSEY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527
Mailing Address - Country:US
Mailing Address - Phone:541-472-7000
Mailing Address - Fax:513-686-6868
Practice Address - Street 1:500 SW RAMSEY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527
Practice Address - Country:US
Practice Address - Phone:541-472-7000
Practice Address - Fax:513-686-6868
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2022-10-18
Deactivation Date:2019-12-04
Deactivation Code:
Reactivation Date:2020-01-03
Provider Licenses
StateLicense IDTaxonomies
ORMD209942207R00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine