Provider Demographics
NPI:1659451045
Name:KELLY, SEAN (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DRIVE SUITE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:123 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2652
Practice Address - Country:US
Practice Address - Phone:207-373-1025
Practice Address - Fax:207-373-1026
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14937207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME041366OtherANTHEM BLUE CROSS
ME050092018OtherRAILROAD MEDICARE
ME195860099Medicaid
ME050092018OtherRAILROAD MEDICARE
MEMM7384Medicare ID - Type Unspecified