1689731085 NPI number — DR. TIMOTHY J KELLY M.D.

Table of content: DR. TIMOTHY J KELLY M.D. (NPI 1689731085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689731085 NPI number — DR. TIMOTHY J KELLY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
TIMOTHY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689731085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 FAIRVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-295-3000
Provider Business Mailing Address Fax Number:
704-295-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S HERLONG AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-3399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-328-1864
Provider Business Practice Location Address Fax Number:
803-328-1865
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  30274 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1506232 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 302746 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA21828218 . This is a "MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P01505878 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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