Provider Demographics
NPI:1649513276
Name:RELLER, KERRY EILEEN (MD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:EILEEN
Last Name:RELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:EILEEN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:708 DRUID RD. E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756
Mailing Address - Country:US
Mailing Address - Phone:727-446-1097
Mailing Address - Fax:727-441-2195
Practice Address - Street 1:708 DRUID RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3914
Practice Address - Country:US
Practice Address - Phone:727-446-1097
Practice Address - Fax:833-941-2542
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME127125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018606700Medicaid