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1053637736

NPI Code Detail

MEDICARE: DR. BRIAN D KELLY MD

MEDICARE: DR. BRIAN D KELLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	50745	AZ
2	208000000X	Pediatrics Physician	258848	MA
3	2080S0010X	Pediatric Sports Medicine Physician	50745	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053637736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN D KELLY MD

Provider Business Mailing Address
First Line	:	1919 E THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7710
Country	:	US
Telephone Number	:	602-933-3033
Fax Number	:	602-933-5245

Provider Business Practice Location Address
First Line	:	1919 E THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7710
Country	:	US
Telephone Number	:	602-933-3033
Fax Number	:	602-933-5245

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	01/11/2023

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Directions to “ DR. BRIAN D KELLY MD” Practice Location

Language	Start Address	Practice Location

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