Provider Demographics
NPI:1366436081
Name:KELLY, CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
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 1:150 E 32ND ST
Mailing Address - Street 2:2ND FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6024
Mailing Address - Country:US
Mailing Address - Phone:646-825-6300
Mailing Address - Fax:
Practice Address - Street 1:150 E 32ND ST
Practice Address - Street 2:2ND FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6024
Practice Address - Country:US
Practice Address - Phone:646-825-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221032208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02167224Medicaid
NY5P2391Medicare ID - Type Unspecified
NY02167224Medicaid