Provider Demographics
NPI:1073599833
Name:KELLY, BENJAMIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
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 1:100 STONEFOREST DR 320
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:770-516-5199
Mailing Address - Fax:678-213-1851
Practice Address - Street 1:100 STONEFOREST DR STE 320
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4881
Practice Address - Country:US
Practice Address - Phone:770-516-5199
Practice Address - Fax:678-213-1851
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48120174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BBSPVMedicare ID - Type Unspecified
GAH59484Medicare UPIN