Provider Demographics
NPI:1437119401
Name:KELLY, KEVIN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
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 1:805 SIR THOMAS CT FL 2
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-657-3030
Mailing Address - Fax:717-671-0991
Practice Address - Street 1:805 SIR THOMAS CT FL 2
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-657-3030
Practice Address - Fax:717-671-0991
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037735E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007100474Medicaid
D71326Medicare UPIN
PA007100474Medicaid