Provider Demographics
NPI:1063631745
Name:KELLY, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
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 1:2296 US 70 HWY
Mailing Address - Street 2:
Mailing Address - City:SWANNANOA
Mailing Address - State:NC
Mailing Address - Zip Code:28778-8209
Mailing Address - Country:US
Mailing Address - Phone:828-686-5232
Mailing Address - Fax:828-686-7269
Practice Address - Street 1:2296 US 70 HWY
Practice Address - Street 2:
Practice Address - City:SWANNANOA
Practice Address - State:NC
Practice Address - Zip Code:28778-8209
Practice Address - Country:US
Practice Address - Phone:828-686-5232
Practice Address - Fax:828-686-7269
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC48212OtherBCBS PROVIDER NUMBER
NC0170087OtherUNITED HEALTH CARE
NC8948212Medicaid
NC152692OtherMID SOUTH
NC210331OtherCIGNA
NC210331OtherCIGNA
NC202648BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NC8948212Medicaid
NC080122960Medicare ID - Type UnspecifiedMEDICARE RR PROVIDER NMBR