Kelly Phommahaxay, M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

59533 Issued in MN

Practice address

8080 Parkway Dr
La Mesa, CA 91942-2104

Phone

(619) 753-5115

NPI assigned

Jun 13, 2014

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in SD, CA2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 2

Specialty

Family Practice

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southern California Permanente Medical GroupGroup PAC ID 6002729175, 11,250 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

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.

• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Baldwin Park, CA
  • NPI 1770515280
  Medicare reassignment Care Compare group NPD
• Monument Health Network, Inc.

  dba Monument Health Hot Springs Clinic

  • Multi-Specialty Clinic/Center
  • Hot Springs, SD
  • NPI 1588185268
  Medicare reassignment NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • San Diego, CA
  • NPI 1225060742
  NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Santa Clarita, CA
  • NPI 1316409410
  NPD
• Monument Health Network, Inc.

  dba Monument Health Custer Clinic

  • Family Medicine Physician
  • Custer, SD
  • NPI 1427243963
  NPD

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

{
    "created_epoch": "1402617600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1705536000000",
    "number": "1770997173",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8080 PARKWAY DR",
            "city": "LA MESA",
            "state": "CA",
            "postal_code": "919422104",
            "telephone_number": "619-753-5115"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8080 PARKWAY DR",
            "city": "LA MESA",
            "state": "CA",
            "postal_code": "919422104",
            "telephone_number": "619-753-5115"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1039 Montgomery St",
            "address_purpose": "LOCATION",
            "city": "Custer",
            "state": "SD",
            "postal_code": "577301304",
            "country_code": "US",
            "telephone_number": "605-673-2229",
            "fax_number": "605-755-0707",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "330 N 8th Ave E",
            "address_purpose": "LOCATION",
            "city": "Duluth",
            "state": "MN",
            "postal_code": "558052024",
            "country_code": "US",
            "telephone_number": "218-723-1112",
            "fax_number": "218-529-9120",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PHOMMAHAXAY",
        "first_name": "KELLY",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-06-13",
        "last_updated": "2024-01-18",
        "certification_date": "2024-01-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "59533",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "4647 Zion Ave",
            "city": "San Diego",
            "state": "CA",
            "country_code": "US",
            "postal_code": "921202507",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Phillip Dickinson, M.D., a Professional Corporation
• Jarrad Marshall Phillips, ATC
• Julie Christine Phillips, M.D.
• Justine Phillips, ATC
• Lanard Phillips Sr.
• Physical Therapy and Sports Medicine Center
• Physician Assistant Surgassist, Inc.
• Physiotherapy Associates, Inc.
• Kate R Pierce
• Rebecca Claire Pierce, DPT

• Family Medicine Physician in La Mesa, CA
• Providers in La Mesa, CA by specialty
• Family Medicine Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.