Provider Demographics
NPI:1740484559
Name:KELLY, GAIL MARIE (MD)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:MARIE
Last Name:KELLY
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:102 W. WATER STREET, SUITE 1
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS, DOVER
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-6750
Practice Address - Country:US
Practice Address - Phone:302-651-6212
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME98073208000000X
DEC10010301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC10010301OtherSTATE LICENSE
FL278341000Medicaid