Basic Information
| Provider Information | |||||||||
| NPI: | 1134172588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | IRIS | ||||||||
| MiddleName: | CHAMBLISS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 657 HEMLOCK ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787458932 | ||||||||
| Practice Location | |||||||||
| Address1: | 657 HEMLOCK ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787458932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23070 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 51448 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 051488 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5562814 | 01 | SC | CIGNA | OTHER | 57-6007863095 | 01 | SC | BCBS OF SC | OTHER | 230707 | 05 | SC | MEDICAID | 57-6007863071 | 01 | SC | BLUE CHOICE OF SC | OTHER | 7649442 | 01 | SC | AETNA | OTHER |