Provider Demographics
NPI:1568415768
Name:BRIDGES, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1686 SKYLYN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-585-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22978207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC229782Medicaid
SCH595876162OtherMEDICARE PIN
SCP00691795OtherRR MEDICARE
SC8688Medicare PIN
SC5878670010Medicare NSC
H59587Medicare UPIN
SC229782Medicaid
SCH595878688Medicare PIN