Healthcare Provider Details

I. General information

NPI: 1467650077
Provider Name (Legal Business Name): KELLY G KILCOYNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 LUBRANO DR STE 202
ANNAPOLIS MD
21401-7369
US

IV. Provider business mailing address

127 LUBRANO DR STE 202
ANNAPOLIS MD
21401-7369
US

V. Phone/Fax

Practice location:
  • Phone: 410-544-4263
  • Fax: 855-394-3899
Mailing address:
  • Phone: 410-544-4263
  • Fax: 855-394-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD75966
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberD75966
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: