Provider Demographics
NPI:1306089230
Name:KELLY, BRIAN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
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 1:555 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2136
Mailing Address - Country:US
Mailing Address - Phone:531-355-6540
Mailing Address - Fax:531-355-0001
Practice Address - Street 1:16929 FRANCES ST STE 101
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-758-5125
Practice Address - Fax:531-255-0001
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59455208000000X, 207K00000X
WI55878207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306089230Medicaid
WI1306089230Medicaid
MNH400224058Medicare PIN
WI73601 2496Medicare PIN