Provider Demographics
NPI:1760402473
Name:KELLY, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:913B BOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-856-9530
Mailing Address - Fax:843-971-1345
Practice Address - Street 1:913 BOWMAN RD # B
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3235
Practice Address - Country:US
Practice Address - Phone:843-856-9530
Practice Address - Fax:843-971-1345
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCTL305262084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8249Medicare PIN
SCAA2813Medicare UPIN