Provider Demographics
NPI:1649499971
Name:KELLY, DEREK M (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-3100
Mailing Address - Fax:901-759-3196
Practice Address - Street 1:1458 W POPLAR AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0630
Practice Address - Country:US
Practice Address - Phone:901-759-3100
Practice Address - Fax:901-759-3196
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2022-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN43223207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174871001Medicaid
MS100169565Medicaid
MS008850343Medicaid
TN1508536Medicaid
MS04951036Medicaid