Healthcare Provider Details

I. General information

NPI: 1275550717
Provider Name (Legal Business Name): BRIAN J. KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11365 DORSETT RD.
MARYLAND HEIGHTS MO
63043
US

IV. Provider business mailing address

11365 DORSETT RD.
MARYLAND HEIGHTS MO
63043
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-6430
  • Fax: 314-872-6500
Mailing address:
  • Phone: 314-872-6430
  • Fax: 314-872-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number105182
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number105182
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number105182
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: