Provider Demographics
NPI:1417985813
Name:KELLEY, GLENN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:PATRICK
Last Name:KELLEY
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 1:4200 HOUMA BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2970
Mailing Address - Country:US
Mailing Address - Phone:504-454-4102
Mailing Address - Fax:504-454-4192
Practice Address - Street 1:4200 HOUMA BLVD FL 2
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2970
Practice Address - Country:US
Practice Address - Phone:504-454-4102
Practice Address - Fax:504-454-4192
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.025489207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1575755Medicaid
LA367361YT3RMedicare PIN