Provider Demographics
NPI:1770574907
Name:KELLEY, SUSAN G (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 US HIGHWAY 1, STE 500
Mailing Address - Street 2:ROSS UNIVERSITY SCHOOL OF MEDICINE
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-3311
Mailing Address - Country:US
Mailing Address - Phone:330-423-0265
Mailing Address - Fax:
Practice Address - Street 1:ROSS UNIVERSITY SCHOOL OF MEDICINE
Practice Address - Street 2:PORTSMOUTH CAMPUS
Practice Address - City:ROSEAU
Practice Address - State:WEST INDIES
Practice Address - Zip Code:00152
Practice Address - Country:DM
Practice Address - Phone:330-423-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-05
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2305151Medicaid
H56458Medicare UPIN