=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770604043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH STEFON KELLY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11701 LIVINGSTON RD STE 308
-----------------------------------------------------
City | FORT WASHINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20744-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-292-6140
-----------------------------------------------------
Fax | 240-559-0895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11701 LIVINGSTON RD STE 308
-----------------------------------------------------
City | FORT WASHINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20744-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-632-6900
-----------------------------------------------------
Fax | 301-632-6901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | D0054969
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------