Healthcare Provider Details

I. General information

NPI: 1114192226
Provider Name (Legal Business Name): BRIAN JOSEPH KELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-4319
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax: 860-679-1430
Mailing address:
  • Phone: 860-679-8080
  • Fax: 860-679-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD454095
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number070803
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: