Provider Demographics
NPI:1275550717
Name:KELLY, BRIAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
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 1:11365 DORSETT RD.
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043
Mailing Address - Country:US
Mailing Address - Phone:314-872-6430
Mailing Address - Fax:314-872-6500
Practice Address - Street 1:11365 DORSETT RD.
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043
Practice Address - Country:US
Practice Address - Phone:314-872-6430
Practice Address - Fax:314-872-6500
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1051822080N0001X, 2080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207674029Medicaid
IL036057823Medicaid
IL036057823Medicaid
370019085Medicare PIN
MO207674029Medicaid