Provider Demographics
NPI:1366947715
Name:KELLY, GINA M (DO , MS)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO , MS
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 26066
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44126-0066
Mailing Address - Country:US
Mailing Address - Phone:816-786-1917
Mailing Address - Fax:
Practice Address - Street 1:23790 ELM RD
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3726
Practice Address - Country:US
Practice Address - Phone:816-786-1917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016941208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty