Provider Demographics
NPI:1609284223
Name:KELLY, BRAD RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:RICHARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PINE ST W
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944-4750
Mailing Address - Country:US
Mailing Address - Phone:803-943-7702
Mailing Address - Fax:
Practice Address - Street 1:1000 PINE ST W
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-4750
Practice Address - Country:US
Practice Address - Phone:803-943-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3239207Q00000X
OH58.005341207Q00000X
SC39359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC393596Medicaid