Provider Demographics
NPI:1750327854
Name:KELLY, FREDERICK WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WAYNE
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 1:1024 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-3544
Mailing Address - Country:US
Mailing Address - Phone:256-543-7406
Mailing Address - Fax:256-543-1661
Practice Address - Street 1:1024 1ST AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901
Practice Address - Country:US
Practice Address - Phone:256-543-7406
Practice Address - Fax:256-543-1661
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051523084Medicaid
051523084OtherBLUE CROSS
P00147324OtherRAILROAD MCARE
051523084KELMedicare ID - Type Unspecified
051523084OtherBLUE CROSS