Provider Demographics
NPI:1871889287
Name:ZACH, KELLY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JOSEPH
Last Name:ZACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7121 STEPHANIE LN
Mailing Address - Street 2:STE 102
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5359
Mailing Address - Country:US
Mailing Address - Phone:402-413-5010
Mailing Address - Fax:402-413-5009
Practice Address - Street 1:7121 STEPHANIE LN
Practice Address - Street 2:STE 102
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5359
Practice Address - Country:US
Practice Address - Phone:402-413-5010
Practice Address - Fax:402-413-5009
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72483207R00000X
NE29166208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR72483OtherTRAINING PERMIT