Provider Demographics
NPI:1447289004
Name:KELLY, JAMES C (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 FAIR HARBOUR PL
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4739
Mailing Address - Country:US
Mailing Address - Phone:860-442-7391
Mailing Address - Fax:860-440-3985
Practice Address - Street 1:59 FAIR HARBOUR PL
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4739
Practice Address - Country:US
Practice Address - Phone:860-442-7391
Practice Address - Fax:860-440-3985
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20534207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D77009Medicare UPIN
5961780001Medicare NSC