Provider Demographics
NPI:1235213851
Name:KELLY, GREGORY B (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
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 1:3100 WYMAN PARK DRIVE
Mailing Address - Street 2:SUITE 359A
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BOULEVARD
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:443-442-2300
Practice Address - Fax:443-442-2360
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD367271900Medicaid
06VVMedicare ID - Type Unspecified
D74668Medicare UPIN