Provider Demographics
NPI:1295787844
Name:KELLY, DESMOND PEYTON (MD)
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:PEYTON
Last Name:KELLY
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC178732080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863094OtherBCBS OF SC
SC1276609OtherCIGNA
SC178738Medicaid
SC576007863037OtherBLUE CHOICE OF SC
SC178738Medicaid
SCC848797951Medicare PIN
SCC848796904Medicare PIN