Provider Demographics
NPI:1851573760
Name:SUE KELLY DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:SUE KELLY DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:401-667-0905
Mailing Address - Street 1:7 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-7135
Mailing Address - Country:US
Mailing Address - Phone:401-667-0905
Mailing Address - Fax:401-667-0590
Practice Address - Street 1:7 WEAVER RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-7135
Practice Address - Country:US
Practice Address - Phone:401-667-0905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00604207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty