Healthcare Provider Details

I. General information

NPI: 1598053803
Provider Name (Legal Business Name): BRIAN KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 02/10/2022
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 JFK DR STE 320
ATLANTIS FL
33462-6641
US

IV. Provider business mailing address

180 JFK DR STE 320
ATLANTIS FL
33462-6641
US

V. Phone/Fax

Practice location:
  • Phone: 561-548-4900
  • Fax: 561-434-5165
Mailing address:
  • Phone: 561-548-4900
  • Fax: 561-434-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME148365
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: