Provider Demographics
NPI:1760826788
Name:FORD, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7695 POPLAR PIKE STE 101
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-5947
Mailing Address - Country:US
Mailing Address - Phone:901-685-2696
Mailing Address - Fax:901-682-9747
Practice Address - Street 1:7695 POPLAR PIKE STE 101
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-5947
Practice Address - Country:US
Practice Address - Phone:901-685-2696
Practice Address - Fax:901-682-9747
Is Sole Proprietor?:No
Enumeration Date:2013-04-21
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN568152085R0202X, 2085R0204X
MS259272085R0202X, 2085R0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program