Provider Demographics
NPI:1740229038
Name:KELLEY, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
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 1:191 DEEP SOUTH FARM RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-2220
Mailing Address - Country:US
Mailing Address - Phone:706-439-6380
Mailing Address - Fax:706-439-6398
Practice Address - Street 1:191 DEEP SOUTH FARM RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2220
Practice Address - Country:US
Practice Address - Phone:706-439-6380
Practice Address - Fax:706-439-6398
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA16253207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000187635IJKMedicaid
GAD45824Medicare UPIN
GA511I060056Medicare PIN