Provider Demographics
NPI:1306826300
Name:WATSON, KELLEY T (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:T
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:TEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3860
Mailing Address - Country:US
Mailing Address - Phone:864-725-4016
Mailing Address - Fax:864-725-5839
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-227-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18984207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC189842Medicaid
SCG360134403Medicare PIN
G36013Medicare UPIN