Provider Demographics
NPI:1033262951
Name:KELLY, ROBERT JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:KELLY
Suffix:JR
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 1:4700 WATERS AVE 1ST FLOOR MUS BLDG
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404
Mailing Address - Country:US
Mailing Address - Phone:912-350-3438
Mailing Address - Fax:912-350-9037
Practice Address - Street 1:4700 WATERS AVENUE
Practice Address - Street 2:1ST FLOOR MUS BLDG
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-8712
Practice Address - Fax:912-350-8753
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD30436208600000X
GA067234208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121278BMedicaid
GAP01070459OtherRAILROAD MEDICARE
GA003121278EMedicaid
SCGA1298Medicaid
GA202I011646Medicare PIN
GA003121278FMedicaid
GA003121278AMedicaid
GA202I011646Medicare PIN
GA003121278GMedicaid
GA003121278CMedicaid
GA003121278HMedicaid