Provider Demographics
NPI:1730197955
Name:KELLY, ALBERT M (DO)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-340-3911
Mailing Address - Fax:760-837-8876
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-837-8876
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A8453207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX84530Medicaid
CA020A84531Medicare PIN
H87541Medicare UPIN
CABH665ZMedicare PIN