Provider Demographics
NPI:1346294022
Name:KELLY, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
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 1:2 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3508
Mailing Address - Country:US
Mailing Address - Phone:813-844-4396
Mailing Address - Fax:813-844-4972
Practice Address - Street 1:2 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3508
Practice Address - Country:US
Practice Address - Phone:813-844-4396
Practice Address - Fax:813-844-4972
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82914207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03171OtherFL BCBS NUMBER
FL262154100Medicaid
FL300802800OtherDOL ACS (FECA) W/C
FL050083047OtherMEDICARE RAILROAD
FL03171ZMedicare ID - Type UnspecifiedFL GTBA MEDICARE
FL050083047OtherMEDICARE RAILROAD
FL300802800OtherDOL ACS (FECA) W/C
FL03171Medicare ID - Type UnspecifiedFL MEDICARE