Provider Demographics
NPI:1578672440
Name:KELLEY, BRENDAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD
Mailing Address - Street 2:SUITE 570
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-6526
Mailing Address - Fax:614-293-4724
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-293-6526
Practice Address - Fax:614-293-4724
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH350920742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2869187Medicaid
OHP01576652OtherRAILROAD MEDICARE
OHP01576652OtherRAILROAD MEDICARE
OH2869187Medicaid
OH2869187Medicaid
MN130001287Medicare PIN