Provider Demographics
NPI:1407158850
Name:JOHN EDWARD KELLY MD PA
Entity Type:Organization
Organization Name:JOHN EDWARD KELLY MD PA
Other - Org Name:JOHN EDWARD KELLY MD PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-212-9200
Mailing Address - Street 1:2401 RESEARCH BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6254
Mailing Address - Country:US
Mailing Address - Phone:301-212-9200
Mailing Address - Fax:
Practice Address - Street 1:2401 RESEARCH BLVD STE 340
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6254
Practice Address - Country:US
Practice Address - Phone:301-212-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0006349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD113251200Medicaid
MDKE173065Medicare PIN
MDD09446Medicare UPIN