Provider Demographics
NPI:1871957761
Name:KIM A KELLY, M.D., P.C.
Entity type:Organization
Organization Name:KIM A KELLY, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-702-2003
Mailing Address - Street 1:5875 ALLENTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4570
Mailing Address - Country:US
Mailing Address - Phone:301-702-2003
Mailing Address - Fax:301-702-2324
Practice Address - Street 1:5875 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-4570
Practice Address - Country:US
Practice Address - Phone:301-702-2003
Practice Address - Fax:301-702-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0039363405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD048510100Medicaid
MD44400001OtherBLUE CHOICE