=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508685413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIM A KELLY, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5873 ALLENTOWN RD
-----------------------------------------------------
City | SUITLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20746-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-702-2003
-----------------------------------------------------
Fax | 301-702-2324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5875 ALLENTOWN RD
-----------------------------------------------------
City | SUITLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20746-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-702-2003
-----------------------------------------------------
Fax | 301-702-2324
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DONA BOWIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-751-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------