Provider Demographics
NPI:1194274951
Name:KELLY RICH FAMILY MEDICINE
Entity type:Organization
Organization Name:KELLY RICH FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:GARDNER
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-859-1483
Mailing Address - Street 1:1215 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 211
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7279
Mailing Address - Country:US
Mailing Address - Phone:470-878-6912
Mailing Address - Fax:470-878-1849
Practice Address - Street 1:1215 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 211
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7279
Practice Address - Country:US
Practice Address - Phone:470-878-6912
Practice Address - Fax:470-878-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047988261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care