NPIMap

Individual provider Active NPI

Roderick Kelly, PA

  • Physician Assistant
  • Fort Polk, LA
National Provider Identifier
1275637472
Registry record updated Sep 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA02232 Issued in TX
Practice address
1585 3Rd St
Fort Polk, LA 71459-5102
Phone
(337) 531-3011
NPI assigned
Sep 11, 2006
Last updated
Sep 16, 2025By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2025

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA200615 LA
Physician Assistant 363A00000X PA02232 TX Primary

Addresses

Primary practice location

1585 3Rd St
Fort Polk, LA 71459-5102

Mailing address

1509 W Loop 281 Ste 2-B
Longview, TX 75604-2820
Phone (903) 759-9355

Other practice location 1

1509 W Loop 281
Suite 2-B
Longview, TX 75604-2820
Phone (903) 759-9355

Other practice location 2

1549 E 70th St Ste 300
Shreveport, LA 71105-5056
Phone (318) 300-3898

Other practice location 3

800 E Dawson St
Tyler, TX 75701-2036
Phone (903) 606-4262

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, LA, NM, NE4 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
I20070430000222 TX Practitioner - Physician Assistant 6002912581 Reassigns benefits to 8 organizations
I20130725000750 LA Practitioner - Physician Assistant 6002912581 Reassigns benefits to 7 organizations
I20220624000548 NM Practitioner - Physician Assistant 6002912581 Reassigns benefits to 2 organizations
I20260403002391 NE Practitioner - Physician Assistant 6002912581 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2000
Medicare assignment
May accept Medicare assignment
Group practices
Concord Medical Group PLLCGroup PAC ID 0446296818, 189 clinicians
Concord Medical Group of Texas PLLCGroup PAC ID 7810117223, 319 clinicians

Practice addresses (Care Compare)

100 Medical Park Dr
Bernice, LA 71222-0302
Phone (318) 285-7777

101 Ave J
Anson, TX 79501-2113
Phone (325) 823-3231

1549 E 70TH St
Suite 300
Shreveport, LA 71105-5056
Phone (318) 300-3898

409 1St St
Bernice, LA 71222-4001

520 E 6TH St
Odessa, TX 79761-4527
Phone (888) 264-0330

600 S Pine St
Deridder, LA 70634-4942
Phone (337) 462-7100

PO Box
Suite 697
Bernice, LA 71222

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
94.47 of 100Reported as group
Improvement activities
40
Cost
73.21

Merit-based Incentive Payment System (MIPS)

Final score
88.68 of 100Reported as group
Quality
82.35
Promoting interoperability
100
Improvement activities
40
Cost
76.6

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
2976OKMDOptometrist
PA200615LAMDPhysician Assistant
PA02232TXMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Concord Medical Group PLLC CurrentSince Sep 13, 2025 Accepting new patients
Ward 3 4 & 10 Hospital Service District of Parish of Union CurrentSince Oct 7, 2025 Accepting new patients
Arklatex Medical Consultants a Medical Corporation CurrentSince Sep 25, 2025 Accepting new patients
Northern Louisiana Emergency Physicians LLP CurrentSince Feb 13, 2019 Accepting new patients
Arklatex Medical Consultants a Medical Corporation Physician Assistant CurrentSince Sep 25, 2025 Accepting new patients
Southwest Emergency Medical Associates of NM PC Physician Assistant CurrentSince Nov 24, 2024 Accepting new patients
Concord Medical Group of Texas PLLC CurrentSince Sep 5, 2025 Accepting new patients
Texas Em-I Medical Services PA CurrentSince Aug 12, 2012 Accepting new patients
Southeast Emergency Physician Associates, P.a. Past Accepting new patients
Texas Trail Emergency Physicians LLC Past Accepting new patients
Texas Emergency Room Services PA Past Accepting new patients
Camino Real Emergency Physicians PLLC Physician Assistant Past Accepting new patients

Locations

100 Medical Park Dr
Bernice, LA 71222
Phone (318) 285-7777

600 S Pine St
Deridder, LA 70634
Phone (337) 462-7100

309 Jackson St
Monroe, LA 71201
Phone (318) 966-4000

401 E Vaughn Ave
Ruston, LA 71270
Phone (318) 254-2100

1549 E 70th St
Ste 300
Shreveport, LA 71105
Phone (318) 300-3898

8731 Park Plaza Dr
Shreveport, LA 71105
Phone (318) 524-7144

601 Martin Luther King Ave NE
Albuquerque, NM 87102
Phone (505) 727-8040

2450 S Telshor Blvd
Las Cruces, NM 88011
Phone (505) 522-8641

101 Avenue J
Anson, TX 79501
Phone (325) 823-3231

200 S Geneva St
Breckenridge, TX 76424
Phone (254) 559-2241

310 W South St
Henrietta, TX 76365
Phone (806) 647-2191

8000 Eldorado Pkwy
McKinney, TX 75070
Phone (469) 424-6400

520 E 6th St
Odessa, TX 79761
Phone (432) 332-0929

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/BCHDDD
  • Direct secure messaging: rkelly5277341@direct.casso.us.com

Organizations & group practices 24

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

View all 24

Hospital & facility affiliations 5

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": "1157932800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1757980800000",
    "number": "1275637472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1509 W LOOP 281 STE 2-B",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "756042820",
            "telephone_number": "903-759-9355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1585 3RD ST",
            "city": "FORT POLK",
            "state": "LA",
            "postal_code": "714595102",
            "telephone_number": "337-531-3011"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1509 W Loop 281",
            "address_2": "Suite 2-B",
            "address_purpose": "LOCATION",
            "city": "Longview",
            "state": "TX",
            "postal_code": "756042820",
            "country_code": "US",
            "telephone_number": "903-759-9355",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1549 E 70th St Ste 300",
            "address_purpose": "LOCATION",
            "city": "Shreveport",
            "state": "LA",
            "postal_code": "711055056",
            "country_code": "US",
            "telephone_number": "318-300-3898",
            "fax_number": "318-797-4241",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "800 E Dawson St",
            "address_purpose": "LOCATION",
            "city": "Tyler",
            "state": "TX",
            "postal_code": "757012036",
            "country_code": "US",
            "telephone_number": "903-606-4262",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELLY",
        "first_name": "RODERICK",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-11",
        "last_updated": "2025-09-16",
        "certification_date": "2025-09-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "LA",
            "license": "PA200615",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA02232",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Polk, LA

Sources for this page

Verify at the official NPI Registry.