Provider Demographics
NPI:1508820424
Name:KELLY, RICHARD JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:840 STEVENS CREEK RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-9251
Practice Address - Country:US
Practice Address - Phone:706-722-6957
Practice Address - Fax:706-722-7454
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0310452085D0003X, 2085U0001X, 2085N0700X, 2085P0229X, 2085R0202X, 2085N0904X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265540314OtherNPI - BROWN & RADIOLOGY
GA00368618GMedicaid
GA00368618EMedicaid
GA00368618CMedicaid
GA00368618HMedicaid
GA00368618IMedicaid
GA00368618BMedicaid
GA00368618JMedicaid
GA00368618FMedicaid
10058872OtherAMERIGROUP
SC102613Medicaid
GA00368618EMedicaid
GA00368618HMedicaid