Provider Demographics
NPI:1083756894
Name:GARRISON, KELLY SOLMS (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SOLMS
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 AUSTELL RD # 22
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1121
Mailing Address - Country:US
Mailing Address - Phone:770-732-4022
Mailing Address - Fax:770-732-4023
Practice Address - Street 1:3950 AUSTELL RD # 22
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-732-4022
Practice Address - Fax:770-732-4023
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041677208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000701434FMedicaid
SCG41677Medicaid
GAP00649634OtherRR MEDICARE
GA511I370122Medicare PIN