Provider Demographics
NPI:1063474419
Name:KELLY, PATRICK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 NE GATEWAY CT NE
Practice Address - Street 2:STE 201
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2414
Practice Address - Country:US
Practice Address - Phone:704-403-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35006207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948233Medicaid
BK3015383OtherDEA
23612OtherCOVENTRY
290011613OtherRAILROAD MEDICARE
NCP00616981OtherRAILROAD MEDICARE, INDIVIDUAL
NC35006OtherNC MEDICAL BOARD
48233OtherBCBS
5124OtherPARTNERS
0441407OtherUNITED HEALTHCARE
NC232009OtherMEDICARE PTAN, GROUP
5220533OtherAETNA
7598588-001OtherCIGNA
NC2180522DOtherMEDICARE PTAN, INDIVIDUAL
89492332180522CMedicare ID - Type Unspecified
NC8948233Medicaid