Healthcare Provider Details

I. General information

NPI: 1952600165
Provider Name (Legal Business Name): SEAN C KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 13TH ST APT 3
BROOKLYN NY
11215-7334
US

IV. Provider business mailing address

364 13TH ST APT 3
BROOKLYN NY
11215-7334
US

V. Phone/Fax

Practice location:
  • Phone: 718-768-2522
  • Fax:
Mailing address:
  • Phone: 718-768-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number234054
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number234054
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: