Provider Demographics
NPI:1306844733
Name:KELLY, WAYNE SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:SCOTT
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1563 HIGHLAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-4324
Mailing Address - Country:US
Mailing Address - Phone:423-478-1958
Mailing Address - Fax:423-473-7339
Practice Address - Street 1:435 25TH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3838
Practice Address - Country:US
Practice Address - Phone:423-479-9733
Practice Address - Fax:423-472-1890
Is Sole Proprietor?:No
Enumeration Date:2005-07-10
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28906208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics