Provider Demographics
NPI:1154314250
Name:KELLY, GORDON M (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:58 BIG A RD
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6017
Mailing Address - Country:US
Mailing Address - Phone:706-886-5624
Mailing Address - Fax:706-827-5096
Practice Address - Street 1:355 CLEAR CREEK PKWY
Practice Address - Street 2:SUITE 1003
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-4174
Practice Address - Country:US
Practice Address - Phone:706-356-4392
Practice Address - Fax:866-787-6602
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-06-16
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Provider Licenses
StateLicense IDTaxonomies
GA33373208600000X
VA0101257941208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000429019CMedicaid
VA1154314250Medicaid
GA02BBCSVMedicare PIN
GA000429019CMedicaid
VA1154314250Medicaid