Provider Demographics
NPI:1629222781
Name:KELLY, BRENDAN S (DO)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:S
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-6713
Mailing Address - Country:US
Mailing Address - Phone:609-441-8146
Mailing Address - Fax:609-441-8002
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-441-8146
Practice Address - Fax:609-441-8002
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-15
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08863500208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist