Provider Demographics
NPI:1437179603
Name:KELLY, SAMUEL S (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:S
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-883-2500
Mailing Address - Fax:
Practice Address - Street 1:5826 SAMET DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-3660
Practice Address - Country:US
Practice Address - Phone:336-878-6540
Practice Address - Fax:336-878-6541
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC080160805OtherRR MEDICARE
NC1212660012OtherDME
NC891269HMedicaid
NC2280838AMedicare PIN
F84941Medicare UPIN
NC1212660012OtherDME