Provider Demographics
NPI:1881801595
Name:KELLY, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:121 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 2550
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2653
Mailing Address - Country:US
Mailing Address - Phone:207-373-1707
Mailing Address - Fax:207-729-6626
Practice Address - Street 1:121 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 2550
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-373-1707
Practice Address - Fax:207-373-1467
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2023-06-30
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Provider Licenses
StateLicense IDTaxonomies
ME009815208600000X
MEMD9815208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME112680099Medicaid
ME112680099Medicaid
ME373173Medicare PIN