Provider Demographics
NPI:1669447850
Name:KELLY, PETER H (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:H
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:310 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2383
Mailing Address - Country:US
Mailing Address - Phone:952-843-4333
Mailing Address - Fax:952-843-4301
Practice Address - Street 1:310 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2393
Practice Address - Country:US
Practice Address - Phone:952-843-4333
Practice Address - Fax:952-843-4301
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN29590174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN392777600Medicaid