Provider Demographics
NPI:1891180113
Name:KELLEY, GREGORY RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:RUSSELL
Last Name:KELLEY
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 1:3025 SHRINE RD STE 390
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4786
Mailing Address - Country:US
Mailing Address - Phone:912-466-7380
Mailing Address - Fax:
Practice Address - Street 1:3025 SHRINE RD STE 390
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4786
Practice Address - Country:US
Practice Address - Phone:912-466-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA896902081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program