Provider Demographics
NPI:1659321453
Name:KELLEY, AMY R (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 JASONWAY AVE
Mailing Address - Street 2:SUITE 1-A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4333
Mailing Address - Country:US
Mailing Address - Phone:614-459-2950
Mailing Address - Fax:614-459-2975
Practice Address - Street 1:770 JASONWAY AVE
Practice Address - Street 2:SUITE 1-A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4333
Practice Address - Country:US
Practice Address - Phone:614-459-2950
Practice Address - Fax:614-459-2975
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-2106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0894055Medicaid
OH0894055Medicaid
OH0730597Medicare PIN