Basic Information
| Provider Information | |||||||||
| NPI: | 1346564044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 SALINA MEADOWS PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154642000 | ||||||||
| FaxNumber: | 3154642010 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 EAST ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154641800 | ||||||||
| FaxNumber: | 3154646238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 266175 | NY | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086X0206X | 266175 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
No ID Information.