Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD020947E | PA |
NPI | 1003846551 |
---|---|
Provider Name | Bruce Richard Kelly |
First Address | Pittsburgh, PA 15238 |
Second Address | Pittsburgh, PA 15238 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 11/10/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
007233260007 | (05) | PA |
0867352 | (05) | OH |
3810010870 | (05) | WV |
C31090 | (02) |