Provider Demographics
NPI:1003803404
Name:KELLY, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:KELLY
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 1:6635 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2354
Mailing Address - Country:US
Mailing Address - Phone:770-968-1323
Mailing Address - Fax:770-968-4556
Practice Address - Street 1:6635 LAKE DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2354
Practice Address - Country:US
Practice Address - Phone:770-968-1323
Practice Address - Fax:770-968-4556
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044256208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000955787AMedicaid
GA000955787DMedicaid
GA000955787FMedicaid
GAH45674Medicare UPIN
GA000955787AMedicaid