Healthcare Provider Details

I. General information

NPI: 1053491787
Provider Name (Legal Business Name): SHANNON MCCLURE KELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW ORTHOPAEDIC SURGERY
WASHINGTON DC
20010-2978
US

IV. Provider business mailing address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2978
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-4063
  • Fax: 202-476-4613
Mailing address:
  • Phone: 202-476-4063
  • Fax: 202-476-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberMD034912
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: