Provider Demographics
NPI:1457305211
Name:KELLY, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:STE 520
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4253
Practice Address - Country:US
Practice Address - Phone:864-455-9033
Practice Address - Fax:864-455-6559
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17203207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC172039Medicaid
SC110247976OtherRR MEDICARE
SC172039Medicaid
SCF884847951Medicare PIN
SC2240105OtherCIGNA
SC110247976OtherRR MEDICARE
SC5667094OtherAETNA
SCF88484Medicare UPIN
SCF884843640Medicare PIN