Healthcare Provider Details

I. General information

NPI: 1043743552
Provider Name (Legal Business Name): KELLY ELIZABETH ORDEMANN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

IV. Provider business mailing address

175 CLOVER ST
ATHENS GA
30606-3066
US

V. Phone/Fax

Practice location:
  • Phone: 504-453-5872
  • Fax:
Mailing address:
  • Phone: 504-453-5872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number323461
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number100848
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: