Provider Demographics
NPI:1770527202
Name:KELLY, TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:477 COOPER RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8053
Mailing Address - Country:US
Mailing Address - Phone:614-898-5561
Mailing Address - Fax:614-898-5563
Practice Address - Street 1:477 COOPER RD
Practice Address - Street 2:SUITE 440
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8053
Practice Address - Country:US
Practice Address - Phone:614-898-5561
Practice Address - Fax:614-898-5563
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042997208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC01651Medicare UPIN