Provider Demographics
NPI:1982675013
Name:KELLY, STEPHEN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1434 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2507
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY127414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00367928Medicaid
NY357141Medicare PIN
NYA400053818Medicare PIN
NY00367928Medicaid