NPIMap

Organization Active NPI

Russell S Kelly MD LLC

  • Primary Care Clinic/Center
  • Ewa Beach, HI
National Provider Identifier
1598810814
Registry record updated Feb 6, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
11807 Issued in HI
Legal business name
RUSSELL S KELLY MD LLC
Practice address
91-2139 Fort Weaver Rd
Suite 300
Ewa Beach, HI 96706-3607
Phone
(808) 678-0700
Fax
(808) 678-0776
NPI assigned
Jan 25, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 6, 2008

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

Authorized official

Name
Dr. Russell S Kelly, M.D.NPI 1790787729
Title
Physician
Phone
(808) 678-0700

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X 11807 HI Primary

Addresses

Primary practice location

91-2139 Fort Weaver Rd
Suite 300
Ewa Beach, HI 96706-3607

Mailing address

91-2139 Fort Weaver Rd
Suite 300
Ewa Beach, HI 96706-3607
Phone (808) 678-0700

Other identifiers 2

IdentifierTypeStateIssuer
0000241885MedicaidHI
53920701MedicaidHI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in HI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070502000010 HI Part B Supplier - Clinic/Group Practice 2365548781 Receives reassigned benefits from 2 practitioners
Practice locations: Ewa Beach, HI

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202256000000",
    "number": "1598810814",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "91-2139 FORT WEAVER RD",
            "address_2": "SUITE 300",
            "city": "EWA BEACH",
            "state": "HI",
            "postal_code": "967063607",
            "telephone_number": "808-678-0700",
            "fax_number": "808-678-0776"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "91-2139 FORT WEAVER RD",
            "address_2": "SUITE 300",
            "city": "EWA BEACH",
            "state": "HI",
            "postal_code": "967063607",
            "telephone_number": "808-678-0700",
            "fax_number": "808-678-0776"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RUSSELL S KELLY MD LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2008-02-06",
        "status": "A",
        "authorized_official_last_name": "KELLY",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "808-678-0700",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "HI",
            "license": "11807",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0000241885",
            "state": "HI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "53920701",
            "state": "HI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ewa Beach, HI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.