1033154810 NPI number — KELLY MEDICAL SERVICES CORPORATION LLC

Table of content: (NPI 1033154810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033154810 NPI number — KELLY MEDICAL SERVICES CORPORATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY MEDICAL SERVICES CORPORATION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KELLY MEDICAL CORPORATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033154810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 634712
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-4712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-203-1274
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
454 MCDOWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELCH
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24801-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-436-8461
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DABBS
Authorized Official First Name:
RANDAL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
865-693-1000

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007378000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001710014 . This is a "WEST VIRGINIA BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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