Provider Demographics
NPI:1023179777
Name:KELLEY, TODD RUFUS (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RUFUS
Last Name:KELLEY
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:85 JOHN MADDOX DRIVE CONNECTOR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1233
Practice Address - Country:US
Practice Address - Phone:762-235-2990
Practice Address - Fax:706-238-8031
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA314567188AMedicaid
GA202I375333Medicare PIN
GA314567188AMedicaid