Provider Demographics
NPI:1902901952
Name:KELLY, TED MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:MARTIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:96 15TH ST NW
Mailing Address - Street 2:104
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1620
Mailing Address - Country:US
Mailing Address - Phone:276-679-8890
Mailing Address - Fax:276-679-9740
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-679-9645
Practice Address - Fax:276-679-9762
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101240536207R00000X
CAG67501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E65038Medicare UPIN