Provider Demographics
NPI:1982067435
Name:GROB, KELLY (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GROB
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 1:1215 LEE ST
Mailing Address - Street 2:BOX 800499
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-5348
Mailing Address - Fax:
Practice Address - Street 1:1517 ROCK SPRING RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2818
Practice Address - Country:US
Practice Address - Phone:410-838-6358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0089246207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine