Provider Demographics
NPI:1053361816
Name:KELLY, MARY ALICE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALICE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1900 RIDGE RD
Mailing Address - Street 2:STE130
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3332
Mailing Address - Country:US
Mailing Address - Phone:716-675-0707
Mailing Address - Fax:716-961-3706
Practice Address - Street 1:1900 RIDGE RD
Practice Address - Street 2:STE 130
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3332
Practice Address - Country:US
Practice Address - Phone:716-675-0707
Practice Address - Fax:716-961-3706
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1568631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0401537OtherIHA
00010089201OtherUNIVERA
000500738001OtherBCBS
D01420Medicare UPIN
B77781Medicare ID - Type Unspecified