Provider Demographics
NPI:1679556344
Name:SUSAN G. KELLEY, M.D., LLC
Entity type:Organization
Organization Name:SUSAN G. KELLEY, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-423-0265
Mailing Address - Street 1:630 US HIGHWAY 1, STE 500
Mailing Address - Street 2:ROSS UNIVERSITY SCHOOL OF MEDICINE
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-3311
Mailing Address - Country:US
Mailing Address - Phone:330-423-0265
Mailing Address - Fax:
Practice Address - Street 1:ROSS UNIVERSITY SCHOOL OF MEDICINE
Practice Address - Street 2:PORTSMOUTH CAMPUS
Practice Address - City:ROSEAU
Practice Address - State:WEST INDIES
Practice Address - Zip Code:00152
Practice Address - Country:DM
Practice Address - Phone:330-423-0265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-26
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-0211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2305151Medicaid
OH36D1041514OtherCLIA
SU9355161Medicare PIN
KE4070872Medicare PIN