Provider Demographics
NPI:1043280241
Name:RICH, KELLY GARDNER (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GARDNER
Last Name:RICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-0443
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:
Practice Address - Street 1:1000 BRABHAM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-1695
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047988207Q00000X
FLME140393207Q00000X
NC202004545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H42014Medicare UPIN