Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0204X | Pediatric Emergency Doctor | 032843 | GA |
NPI | 1295793172 |
---|---|
Provider Name | Dr. Phillip Brian Kelley |
First Address | Suwanee, GA 30024-5436 |
Second Address | Atlanta, GA 30342-1605 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E87169 | (02) | GA |