Basic Information
| Provider Information | |||||||||
| NPI: | 1649499971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1458 W POPLAR AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380170630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | 43223 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 174871001 | 05 | AR | MEDICAID | 100169565 | 05 | MS | MEDICAID | 008850343 | 05 | MS | MEDICAID | 1508536 | 05 | TN | MEDICAID | 04951036 | 05 | MS | MEDICAID |