Healthcare Provider Details

I. General information

NPI: 1508027046
Provider Name (Legal Business Name): KELL MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DR STE F
JACKSONVILLE NC
28546-6308
US

IV. Provider business mailing address

200 DOCTORS DR STE F
JACKSONVILLE NC
28546-6308
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-1499
  • Fax: 910-355-0404
Mailing address:
  • Phone: 910-353-1499
  • Fax: 910-355-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number9600132
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E KELL
Title or Position: PRIMARY DOCTOR
Credential: M.D.
Phone: 910-353-1499