Provider Demographics
NPI:1023044963
Name:KELLY, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FRANCIS STREET
Mailing Address - Street 2:SUITE 8E
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-632-8623
Mailing Address - Fax:
Practice Address - Street 1:110 FRANCIS ST
Practice Address - Street 2:SUITE 8E
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5501
Practice Address - Country:US
Practice Address - Phone:617-632-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45873207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0142859Medicaid
MA30279OtherHARVARD PILGRIM
MAD95066Medicare UPIN
MAE05502Medicare ID - Type UnspecifiedMEDICARE/BLUE SHIELD