Provider Demographics
NPI:1114939212
Name:KELLEY, SCOTT STREATER (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:STREATER
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 1:3609 SOUTHWEST DURHAM DRIVE
Mailing Address - Street 2:NORTH CAROLINA ORTHOPAEDIC CLINIC
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6507
Mailing Address - Country:US
Mailing Address - Phone:919-403-5151
Mailing Address - Fax:
Practice Address - Street 1:3609 SW DURHAM DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6507
Practice Address - Country:US
Practice Address - Phone:919-403-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35942207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A03606Medicare UPIN
2175939AMedicare ID - Type Unspecified