Provider Demographics
NPI:1699753921
Name:SOMMERVILLE-KELLEY, MOYA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:MOYA
Middle Name:ELIZABETH
Last Name:SOMMERVILLE-KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:770-749-1119
Practice Address - Street 1:750 TOWN PARK LANE
Practice Address - Street 2:KAISER PERMANENTE TOWN PARK MEDICAL OFFICE
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:770-749-1119
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA056924207Q00000X
GA56924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA197234226BMedicaid
GA197234226EMedicaid
GA197234226FMedicaid
GA197234226CMedicaid
GA197234226DMedicaid
GA197234226CMedicaid
GA08CBCQJMedicare PIN
GAH51695Medicare UPIN