1710972385 NPI number — KEVIN GERARD KELLY

Table of content: KEVIN GERARD KELLY (NPI 1710972385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710972385 NPI number — KEVIN GERARD KELLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
KEVIN
Provider Middle Name:
GERARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1710972385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13150 HIGHWAY 43
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35653-4558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-332-5901
Provider Business Mailing Address Fax Number:
256-332-6911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13150 HIGHWAY 43
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-4558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-332-5901
Provider Business Practice Location Address Fax Number:
256-332-6911
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  8497 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000001253 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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