NPIMap

Individual provider Active NPI

David J Kelly, MD

  • Family Medicine Physician
  • Eagle, ID
National Provider Identifier
1194862417
Registry record updated Apr 4, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
M-17694 Issued in ID
Practice address
3217 W Bavaria St
Eagle, ID 83616-5171
Phone
(208) 302-6200
Fax
(208) 302-6255
NPI assigned
Jan 30, 2007
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MD155014 OR
Family Medicine Physician 207Q00000X M-17694 ID Primary
Family Medicine Physician 207Q00000X 47273 WI
Family Medicine Physician 207Q00000X M-9938 ID

Addresses

Primary practice location

3217 W Bavaria St
Eagle, ID 83616-5171

Mailing address

PO Box 190930
Boise, ID 83719-0930
Phone (208) 367-5170

Other practice location 1

929 SW Simpson Ave
Ste 300
Bend, OR 97702-3118
Phone (541) 706-3804

Other identifiers 1

IdentifierTypeStateIssuer
807768800MedicaidID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070905000047 ID Practitioner - Family Practice 0840251740 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Sports Medicine
Education
Other, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Saint Alphonsus Regional Medical Center IncGroup PAC ID 3476462359, shared by 4 NPIs, 672 clinicians

Practice addresses (Care Compare)

10717 W State St
Star, ID 83669-6046
Phone (208) 302-6300

3025 W Cherry LN
Meridian, ID 83642-8531

3217 W Bavaria St
Eagle, ID 83616-5171
Phone (208) 302-1400

Hospital & facility affiliations

  • Saint Alphonsus Regional Medical Center Hospital, Boise, ID, CCN 130007
  • Saint Alphonsus Medical Center - Nampa Hospital, Nampa, ID, CCN 130013
  • St Luke'S Regional Medical Center Hospital, Boise, ID, CCN 130006

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
9938IDMDMarriage & Family Therapist
M-9938IDMDFamily Medicine Physician
47273WIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Saint Alphonsus Regional Medical Center Inc CurrentSince Jun 1, 2024 Accepting new patients
Saint Alphonsus Regional Medical Center Inc Current Accepting new patients
Saint Alphonsus Regional Medical Center Inc CurrentSince Jun 1, 2024 Accepting new patients
Caldwell Internal Medicine Professional Association Past Accepting new patients
West Valley Medical Group LLC PastSince Oct 1, 2006 Accepting new patients
West Valley Medical Group Specialty Services LLC Past Accepting new patients
Mercy Physician Group Inc. Past Accepting new patients

Locations

3217 W Bavaria St
Eagle, ID 83616
Phone (208) 286-6676

3025 W Cherry Ln
Ste B
Meridian, ID 83642
Phone (208) 302-6400

4400 E Flamingo Ave
Ste 301
Nampa, ID 83687
Phone (208) 465-6900

10717 W State St
Star, ID 83669
Phone (208) 302-6300

Interoperability endpoints

  • Direct secure messaging: dkelly3393975@direct.trinity-health.org

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712188800000",
    "number": "1194862417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 190930",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837190930",
            "telephone_number": "208-367-5170",
            "fax_number": "208-367-5180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3217 W BAVARIA ST",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836165171",
            "telephone_number": "208-302-6200",
            "fax_number": "208-302-6255"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "929 SW Simpson Ave",
            "address_2": "Ste 300",
            "address_purpose": "LOCATION",
            "city": "Bend",
            "state": "OR",
            "postal_code": "977023118",
            "country_code": "US",
            "telephone_number": "541-706-3804",
            "fax_number": "541-278-8376",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELLY",
        "first_name": "DAVID",
        "middle_name": "J",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-30",
        "last_updated": "2024-04-04",
        "certification_date": "2024-04-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD155014",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M-17694",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "47273",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M-9938",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807768800",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Eagle, ID

Sources for this page

Verify at the official NPI Registry.