Provider Demographics
NPI:1497776579
Name:KANE, KELLY ROSE (MD)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ROSE
Last Name:KANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ROSE
Other - Last Name:TIERNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:235 SHORE RD STE C
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2655
Mailing Address - Country:US
Mailing Address - Phone:609-705-7546
Mailing Address - Fax:
Practice Address - Street 1:235 SHORE RD STE C
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2655
Practice Address - Country:US
Practice Address - Phone:609-705-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA244172207N00000X, 207ND0900X
NJ25MA09419600207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00629167OtherMEDICARE, RAILROAD
MA001747902Medicare PIN
MNP00629167OtherMEDICARE, RAILROAD
I55289Medicare UPIN