MEDICARE: ROBERT O KELLY M.D.

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	207Q00000X	Family Medicine Physician	34384	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	034384	OTHER	GA	MED LIC NUMBER
2	11D0898435	OTHER	GA	CLIA

General Provider Information

NPI Number	:	1386619526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT O KELLY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 742616
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2616
Country	:	US
Telephone Number	:	770-219-8420
Fax Number	:

Provider Business Practice Location Address
First Line	:	3931 MUNDY MILL RD.
Second Line	:
City	:	OAKWOOD
State	:	GA
Zip	:	30566
Country	:	US
Telephone Number	:	770-503-1481
Fax Number	:	770-503-1520

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

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	03/07/2023

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