Provider Demographics
NPI:1851786883
Name:KELLY, BRIAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:KELLY
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 1:7489 SUTHERLAND CIRCLE
Mailing Address - Street 2:BLDG 7489
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:719-526-8882
Mailing Address - Fax:719-526-8883
Practice Address - Street 1:7489 SUTHERLAND CIRCLE
Practice Address - Street 2:BLDG 7489
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-526-4911
Practice Address - Fax:719-526-8883
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7037204R00000X, 2081P0301X, 2081S0010X, 208100000X
OH35.135837208100000X, 2081P0301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0341279.Medicaid