Provider Demographics
NPI:1902862402
Name:KELLY, ANN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3300
Mailing Address - Country:US
Mailing Address - Phone:863-234-5800
Mailing Address - Fax:864-284-0844
Practice Address - Street 1:319 S BUNCOMBE RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1207
Practice Address - Country:US
Practice Address - Phone:864-877-3883
Practice Address - Fax:864-877-7937
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13547174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC13547OtherSTATE LICENSE
SC135473Medicaid
SCC602351Medicare UPIN