1295947844 NPI number — LAWRENCE B. KELLY, MD PLLC

Table of content: (NPI 1295947844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295947844 NPI number — LAWRENCE B. KELLY, MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE B. KELLY, MD PLLC
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:
Provider Other Organization Name Type Code:
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:
1295947844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25339-1850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-343-1022
Provider Business Mailing Address Fax Number:
304-343-1025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4825 MACCORKLE AVE SW STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25309-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-343-1022
Provider Business Practice Location Address Fax Number:
304-343-1025
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
BENNETT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-343-1022

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810011496 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001720795 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: DN1230 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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