Provider Demographics
NPI:1003846551
Name:KELLY, BRUCE RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RICHARD
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 1:320 GUYS RUN ROAD
Mailing Address - Street 2:PO BOX 11460
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238
Mailing Address - Country:US
Mailing Address - Phone:412-435-0005
Mailing Address - Fax:412-435-0003
Practice Address - Street 1:320 GUYS RUN ROAD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238
Practice Address - Country:US
Practice Address - Phone:412-435-0005
Practice Address - Fax:412-435-0003
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020947E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0867352Medicaid
PA007233260007Medicaid
WV3810010870Medicaid
PAP00469282Medicare PIN
C31090Medicare UPIN
PA129310NJKMedicare PIN