Provider Demographics
NPI:1194727628
Name:KELLY, LARRY W (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-527-7000
Mailing Address - Fax:
Practice Address - Street 1:64 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7963
Practice Address - Country:US
Practice Address - Phone:843-314-1314
Practice Address - Fax:843-314-1307
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20643207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT47633Medicaid
SCT47633Medicaid