Provider Demographics
NPI:1588690382
Name:GROW, KELLY C (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:GROW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1001 SUMMIT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6410
Mailing Address - Country:US
Mailing Address - Phone:770-989-1668
Mailing Address - Fax:706-369-9673
Practice Address - Street 1:340 N MILLEDGE AVE STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3806
Practice Address - Country:US
Practice Address - Phone:706-548-0008
Practice Address - Fax:706-369-9673
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051353207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA382474810HMedicaid
GAI54735Medicare UPIN
GA382474810AMedicaid