Provider Demographics
NPI:1912183781
Name:KEITH S KELLY MD PC
Entity Type:Organization
Organization Name:KEITH S KELLY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-632-6900
Mailing Address - Street 1:7627 LEONARDTOWN RD
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:HUGHESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20637-3005
Mailing Address - Country:US
Mailing Address - Phone:301-632-6900
Mailing Address - Fax:301-632-6901
Practice Address - Street 1:7627 LEONARDTOWN RD
Practice Address - Street 2:SUITE 103A
Practice Address - City:HUGHESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20637-3005
Practice Address - Country:US
Practice Address - Phone:301-632-6900
Practice Address - Fax:301-632-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054969207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402RMedicare PIN
G99907Medicare UPIN
DCG01000Medicare PIN