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General NPI Number Information
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NPI Number | 1609284223
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Entity Type | Individual
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Provider Name | BRAD RICHARD KELLY D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 1000 PINE ST W
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City | VARNVILLE
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State | SC
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Zip | 29944-4750
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Country | US
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Telephone | 803-943-7702
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 PINE ST W
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City | VARNVILLE
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State | SC
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Zip | 29944-4750
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Country | US
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Telephone | 803-943-7702
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R3239
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 58.005341
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 39359
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License Number State | SC
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