Healthcare Provider Details

I. General information

NPI: 1891180113
Provider Name (Legal Business Name): GREGORY RUSSELL KELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 SHRINE RD STE 390
BRUNSWICK GA
31520-4786
US

IV. Provider business mailing address

3025 SHRINE RD STE 390
BRUNSWICK GA
31520-4786
US

V. Phone/Fax

Practice location:
  • Phone: 912-466-7380
  • Fax:
Mailing address:
  • Phone: 912-466-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number89690
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number89690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: