Provider Demographics
NPI:1376599845
Name:KELLY, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:100 S MAIN ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1477
Mailing Address - Country:US
Mailing Address - Phone:302-659-4520
Mailing Address - Fax:302-659-4525
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1477
Practice Address - Country:US
Practice Address - Phone:302-659-4520
Practice Address - Fax:302-659-4525
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2013-01-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DEC10004427207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001017201Medicaid
DE0001017201Medicaid
DE00B088M24Medicare PIN