MEDICARE: DR. FREDERICK WAYNE 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	207Q00000X	Family Medicine Physician	17437	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	051523084	OTHER	BLUE CROSS
3	P00147324	OTHER	RAILROAD MCARE

General Provider Information

NPI Number	:	1750327854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK WAYNE KELLY MD

Provider Business Mailing Address
First Line	:	310 W GRAND AVE
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-3236
Country	:	US
Telephone Number	:	256-459-5132
Fax Number	:	256-459-5179

Provider Business Practice Location Address
First Line	:	310 W GRAND AVE
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-3236
Country	:	US
Telephone Number	:	256-459-5132
Fax Number	:	256-459-5179

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

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	09/10/2025

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