Provider Demographics
NPI:1013945211
Name:KELLEY, GEORGIA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:ANN
Last Name:KELLEY
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 1:100 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2365
Mailing Address - Country:US
Mailing Address - Phone:203-234-1891
Mailing Address - Fax:203-234-2678
Practice Address - Street 1:100 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2365
Practice Address - Country:US
Practice Address - Phone:203-234-1891
Practice Address - Fax:203-234-2678
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034092207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0488063OtherAETNA
CT010034092CT01OtherANTHEM BCBS
CT061535742OtherUNITED HEALTHCARE
CTP499703OtherOXFORD
CT01034092OtherCIGNA
CT001340926Medicaid
CT110180478OtherRAILROAD MEDICARE
CT340920OtherCTCARE
CT0Q1536OtherHEALTHNET
CT001340926Medicaid
CT110007460Medicare ID - Type UnspecifiedMEDICARE