Basic Information
| Provider Information | |||||||||
| NPI: | 1508820424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1705 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309031705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067747263 | ||||||||
| FaxNumber: | 7067747230 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 STEVENS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309079251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067226957 | ||||||||
| FaxNumber: | 7067227454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085D0003X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085U0001X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085P0229X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0904X | 031045 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085B0100X | 031045 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 1265540314 | 01 | NPI - BROWN & RADIOLOGY | OTHER | 00368618G | 05 | GA | MEDICAID | 00368618E | 05 | GA | MEDICAID | 00368618C | 05 | GA | MEDICAID | 00368618H | 05 | GA | MEDICAID | 00368618I | 05 | GA | MEDICAID | 00368618B | 05 | GA | MEDICAID | 00368618J | 05 | GA | MEDICAID | 00368618F | 05 | GA | MEDICAID | 10058872 | 01 | AMERIGROUP | OTHER | 102613 | 05 | SC | MEDICAID |