Provider Demographics
NPI:1417952185
Name:KELLY, DONALD SHANE (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:SHANE
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 1:2000A SOUTHBRIDGE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7718
Mailing Address - Country:US
Mailing Address - Phone:205-871-4274
Mailing Address - Fax:205-871-4301
Practice Address - Street 1:50 MEDICAL PARK DR E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3401
Practice Address - Country:US
Practice Address - Phone:205-838-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL174362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051513028OtherBLUE CROSS
AL009938634Medicaid
AL051513024OtherBLUE CROSS
AL051513033OtherBLUE CROSS
AL009938638Medicaid
AL7996461OtherAETNA
AL009938636Medicaid
AL009938641Medicaid
AL051513026OtherBLUE CROSS
AL009938639Medicaid
AL009985785Medicaid
AL051513027OtherBLUE CROSS
AL051513030OtherBLUE CROSS
AL051525309OtherBLUE CROSS
AL051539833OtherBLUE CROSS
AL009938642Medicaid
AL051513024Medicaid
AL051513031OtherBLUE CROSS
AL009938633Medicaid
AL009938637Medicaid
AL051513025OtherBLUE CROSS
AL009938633Medicaid
AL009938637Medicaid
AL009938636Medicaid