Provider Demographics
NPI:1316979180
Name:KELLY, SUSAN MALKIN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MALKIN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4960
Mailing Address - Country:US
Mailing Address - Phone:617-495-2323
Mailing Address - Fax:
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-495-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD104802084P0800X
MA2079902084P0800X
CODR.00608912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISK37242Medicaid
RI1104801349OtherBUTLER HOSPITAL NPI
RI007010632OtherMEDICARE ID-TYPE UNSPECIFIED
1093831646OtherBUTLER HOSPITAL PROFESSIONAL BILLING OFFICE NPI
RI24196-0OtherBLUE CROSS
RI410419OtherBLUE CHIP
RISK37242Medicaid
1093831646OtherBUTLER HOSPITAL PROFESSIONAL BILLING OFFICE NPI