Provider Demographics
NPI:1033280466
Name:KELLY, BYRON THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:THOMAS
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 1:445 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-294-3835
Mailing Address - Fax:404-508-7795
Practice Address - Street 1:445 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1707
Practice Address - Country:US
Practice Address - Phone:404-294-3835
Practice Address - Fax:404-508-7795
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00455749AMedicaid
GA00455749AMedicaid
GA08BBTFJMedicare ID - Type Unspecified