Basic Information
| Provider Information | |||||||||
| NPI: | 1306927900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107152164 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | K8775 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | K8775 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LC0200X | 2019-00087 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 037266605 | 05 | TX | MEDICAID | P00616427 | 01 | TX | MEDICARE RAILROAD | OTHER | 037266604 | 05 | TX | MEDICAID | 37266601 | 05 | TX | MEDICAID | 8AC774 | 01 | TX | BLUE CROSS | OTHER | 1306927900 | 05 | NC | MEDICAID | 1888397 | 05 | LA | MEDICAID |