Provider Demographics
NPI:1356431589
Name:MALONEY, KELLY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MALONEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:540 PHYSICIANS LN
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-3370
Mailing Address - Country:US
Mailing Address - Phone:803-340-5100
Mailing Address - Fax:803-848-8134
Practice Address - Street 1:222 E MEDICAL LN STE 101
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4850
Practice Address - Country:US
Practice Address - Phone:803-739-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31659208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900370Medicaid
SCQ0008FMedicaid
NC2037585Medicare ID - Type Unspecified
SCQ0008FMedicaid
SCAA38897651Medicare PIN