Healthcare Provider Details

I. General information

NPI: 1740415884
Provider Name (Legal Business Name): KEVIN P. KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

2641 N CHARLES ST
BALTIMORE MD
21218-4514
US

V. Phone/Fax

Practice location:
  • Phone: 410-728-5399
  • Fax:
Mailing address:
  • Phone: 410-466-5325
  • Fax: 410-366-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0043878
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: