Provider Demographics
NPI:1033233192
Name:KELLY, BRENDAN PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:PATRICK
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 1:22 DEL PRADO ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1312
Mailing Address - Country:US
Mailing Address - Phone:503-305-6577
Mailing Address - Fax:503-305-6577
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-5750
Practice Address - Fax:503-418-5793
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080000208000000X
ORMD293082080P0202X
WAMD600953702080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics