Provider Demographics
NPI:1083676498
Name:KELLEY, LAURENCE R (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:R
Last Name:KELLEY
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 1:15215 SHADY GROVE RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3235
Mailing Address - Country:US
Mailing Address - Phone:301-990-0040
Mailing Address - Fax:301-990-0043
Practice Address - Street 1:15215 SHADY GROVE RD
Practice Address - Street 2:SUITE 306
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3235
Practice Address - Country:US
Practice Address - Phone:301-990-0040
Practice Address - Fax:301-990-0043
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047655207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53607302OtherBCBS OF MD INDIVIDUAL #
DC4787OtherBCBS OF DC GROUP NUMBER
MDH830OtherBCBS OF MD GROUP NUMBER
DC0009OtherBCBS OF DC INDIVIDUAL #
DC4787OtherBCBS OF DC GROUP NUMBER
DC409823Medicare PIN
DC0009OtherBCBS OF DC INDIVIDUAL #
DC1083676498Medicare PIN
DC1912021619Medicare PIN